# 2 hernias and 1 mesh



## ch81059 (Apr 29, 2014)

I'm thinking that I can only bill for one hernia in this case since it is with the same piece of mesh but I want to make sure.  I believe I will just code 49653 once.  Please see operative report below.

Date of Service: April 14, 2014

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS
Umbilical hernia.

POSTOPERATIVE DIAGNOSES
1. Epigastric hernia, incarcerated.
2. Incarcerated umbilical hernia.

PROCEDURES PERFORMED
Laparoscopic repair of umbilical and epigastric incarcerated hernias
with mesh, 18 x 24 cm DualMesh Plus.

ANESTHESIA
General endotracheal.

ESTIMATED BLOOD LOSS
30 mL.

COMPLICATIONS
None.

SPECIMENS
None.

FINDINGS
1. Approximately 3 cm epigastric hernia defect.
2. Approximately 2 cm umbilical hernia defect, both with incarcerated
omentum.
3. Diastasis.

PROCEDURE IN DETAIL
After informed consent was obtained, the patient was taken to the
operating room and laid supine on the operating table. The abdomen was
prepped and draped in a standard sterile fashion. General endotracheal
anesthesia was induced. Patient received preoperative antibiotics and
DVT prophylaxis. A time-out performed and a 5 mm left upper quadrant
skin incision made. The abdomen was entered using a 5 mm bladeless
optical trocar under direct visualization with the laparoscopic camera.
Once within the abdomen, the abdomen was insufflated to 15 mmHg and the
laparoscopic camera introduced. There were no apparent bowel injuries
upon entry. The remainder of the abdomen was inspected and appeared to
be within normal limits, with the exception of approximately 3 cm
epigastric hernia with incarcerated omentum, as well as an approximately
2 cm umbilical hernia with incarcerated omentum. At this time, 2 rightsided
5 mm trocars were placed under direct visualization; 1 in the
right upper quadrant and 1 in the right lower quadrant. Then, a left
lower quadrant 5 mm trocar was placed under direct visualization.
Laparoscopic graspers were used to reduce the omentum from the
incarcerated epigastric hernia defect. There were some areas of denser
scar tissue that required sharp dissection with shears, as well as
electrocautery for hemostasis. The entirety of the omentum was able to
be reduced entirely from the epigastric fascial defect.

Attention was then turned to the umbilical defect, which reduced easily
with some gentle traction from the laparoscopic grasper. The falciform
ligament was then taken down using sharp dissection and electrocautery,
exposing the area large enough to accommodate an 18 x 24 DualMesh Plus.
This provided more that adequate coverage superiorly and inferiorly over
the 2 hernia defects, as well as good lateral coverage. The
measurements were marked on the exterior surface of the patient's
abdomen, and the mesh then marked superiorly, inferiorly and at its
lateral points and the mid points. Two Gore 2-0 sutures were placed at
the inferior and superior mid points of the mesh, and the corners of the
rectangular mesh rounded to make an oval shape. The mesh was then
folded and rolled, and brought into the abdomen through the right upper
quadrant incision under direct visualization. The mesh then unfolded,
and the superior and inferior Gore-Tex stay sutures tacked in place
using the Gore suture passer at the previously measured external marks,
marking the superior and inferior extent of the mesh. The SorbaFix suture tacker was then used to tack the mesh at its lateral mid points
on the right and left side. The mesh was then inspected. It appeared
to be adequately covering the hernia defect and centered about the
defect, and the mesh tacked in place circumferentially using the
SorbaFix tacker. Two rows of tacks were used, with the outer most ring
of tacks placed approximately 1 cm apart and inner tacks placed
approximately 2 cm apart. Once the mesh had been tacked
circumferentially with 2 layers, transfascial sutures were placed; a
total of 4 sutures placed in the right upper, left upper, right lower,
and left lower quadrants. These were placed with the Gore suture passer
using 2-0 Gore-Tex suture under direct visualization with the
laparoscopic camera. At the end of the case, there was noted to be a
small amount of blood pooling in the area of the reduced omentum. This
was inspected and suction irrigator used to remove blood clot. There
was 1 small vessel that was noted to be bleeding. This was controlled
with electrocautery and the remainder of the abdomen appeared to be
hemostatic without any evidence of active bleed. The mesh was well
positioned with adequate coverage, and at this time the abdomen
desufflated, trocars were removed, and the skin closed with subcuticular
Monocryl suture, and dressed with Mastisol, Steri-Strips and Band-Aids.
The patient awakened from anesthesia and sent to recovery in stable
condition.

Thanks so much for your assistance!


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## cynthiabrown (Apr 29, 2014)

I would only code one as well


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## kimberliterpstra (May 21, 2014)

If both hernias were performed laparoscopically, you may not bill for any mesh.  49652 and 49653 both include "includes mesh insertion, when performed."  

Even if the umbilical hernia was not laparoscopic, you can only bill for mesh for open incisional and/or ventral hernias.

-Kim


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