# Multiple hernia repair vs defect



## Trendale (Sep 17, 2009)

Hello,
Can someone explain to me when I should code a multiple hernia repair. I am gathering bits and pieces from other responses. This is what I have so far: If the hernias was repaired all through the same incision, you just code it once with a mod 22 and submit the notes with claim or if separate incision still a 22. Another response was, If it was repaired through separate incisions, you would code it twice with a 59, and I read some where in this forum, to use 76 and another modifier , can't exactly remember the other mod, nevertheless, which one is correct? 
I am currently working on one now, and because I don't have all of the pieces to this puzzle, not sure what to code. Please take a look and let me know.  looks like only defects

Also is there a link to explain all of this?



OPERATIVE REPORT
DATE:  
NAME OF OPERATIONS:
1  Diagnostic laparoscopy.
2  Lysis of adhesions.
3  Repair of internal hernia times 2.
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:

ANESTHESIA:  General with intubation.
ESTIMATED BLOOD LOSS:  About 25 cc.
INDICATIONS FOR THE PROCEDURE:  The patient is a 35-year-old Hispanic
female who had a gastric bypass done about 2 years ago.  The patient
had presented to my office complaining of a postprandial periumbilical
crampy-like abdominal pain.  I told the patient that likely she is
suffering from internal hernia with volvulus of the small intestines
and she was taken to the operating room for repair.
GROSS OPERATIVE FINDINGS:  Upon entering the abdomen, we immediately
noticed a volvulus of the small intestines through a Peterson defect
between the transverse colon and the Roux limb.  There was also a
defect at the jejunojejunostomy, but this did not contain any
intestine, but was nevertheless it was closed.
DESCRIPTION OF OPERATION:  The patient was brought to the operating
room, positioned on the operating table in supine fashion.  After
induction of anesthesia with intubation, abdomen was prepped and
draped in the usual sterile fashion.  Using 0.5% Marcaine plain, we
made a small incision in the left upper quadrant subcostal
midclavicular line.  Using the 0-degree scope with the Xcel ports, we
went through different layers of the abdomen.  Abdomen was entered and
insufflated with CO2 to 15 mmHg.  Under direct laparoscopic vision, we
placed a 5 mm port in the left upper quadrant subcostal midclavicular
line and a second port was now placed inferior to this one.  A third 5
mm port was now placed in the left upper quadrant subcostal mid
axillary line, which my assistant used.  Immediately using the
LigaSure, we began taking down some of adhesions.  We identified the
omentum, which was brought over toward the liver.  We now looked
underneath.  We identified the Roux limb and noticed how some small
bowel had volvulized with volvulus of the small intestines below and
posterior to limb Roux limb in Peterson space.  We immediately began
running the small intestine, bringing it out of the internal hernia.
We continued doing this until we were able to completely remove the
small intestine from the internal hernia, leaving us with a Peterson
defect.  We now used a running 0 silk to slowly close this defect in a
running non-interrupted fashion.  At this time, we now began running
the Roux limb until we came upon the jejunojejunostomy.  There was a
small defect at this site and although it did not contain any
intestines, we went ahead and repaired it.
Again, using an 0 silk stitch, we closed the stitches in a running
fashion, approximating the mesentery and thus closing this defect and
therefore preventing any future incarceration at this site.  At this
time, we ran the small intestine again to make sure that it was
completely liberated from the internal hernia and there was no further
volvulus.  Once we did this to satisfaction, the abdomen was
irrigated, deflated, trocars removed, and closure was performed.
Closure of the skin incision was done with 4-0 Monocryl in a
subcuticular fashion, followed by Benzoin and Steri-Strips.  Patient
tolerated the procedure quite well.  She was then taken to recovery in
stable condition.


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## nlbarnes (May 26, 2016)

*Multiple hernias*

Hi - I could only look really quick because of month end, but I'm thinking  the unlisted code 44238 for the lap volvulus, maybe the unlisted code 49659 for the Peterson's defect, & when I did the CCI edits, it allowed  the 44180 for the lysis of adhesions (I'm not sure if it allowed it because of the unlisted codes as I'm not used to the lysis being separately billable).  Been out of the game for a bit.


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