# 2nd request, cooper's ligament repair?



## BFAITHFUL (Jan 10, 2011)

Op report states excision of mass and removal of mesh But then goes on to describe a cooper's ligament repair, a modified ferguson type technique.  What cpt code can I use for this type of procedure.  
Dx is painful right inguinal hernia

Thanks


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## preserene (Jan 10, 2011)

The McVay (*Cooper Ligament) approach is popular for larger inguinal hernias and direct or recurrent hernias. *

Whereas the Bassini approach used to be a popular approach but is not used as often today due to the tensionfree approach. It is used for indirect inguinal hernias and small direct hernias.
The  Halstead-Ferguson technique transplants the spermatic cord 
externally to the external oblique. This leaves the cord in the normal anatomical position. 

For coding purpose, it is better we do not confuse ourselves with such terms. But all that we would know is that it is a procedure for direct, large and recurrent hernias.
*So kindly check if there is a document showing recurrence, or incarceration/strangulation of an inguinal hernia for our code selection.*. Presence of mesh there and its removal implies it was recurrent.
   ........................................
[This following info is optional to know at this juncture:     Cooper Ligament approach is popular for larger inguinal hernias and direct or recurrent hernias. It involves suturing the conjoined tendon to the Cooper ligament from the pubic tubercle laterally to the 
femoral canal. The femoral canal must be narrowed for this approach. The repair is extended from the femoral canal to the Coopers ligament anteriorly so that the conjoined tendon is tied to the inguinal ligament past the canal. The internal inguinal ring is then recreated with a space large enough to fit the tip of a Kelly clamp. ]

I hope this throws some light on our dilemma in coding. 
Thank you


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## BFAITHFUL (Jan 11, 2011)

After some research, patient had an inguinal hernia repair on 10/2009, and the reason why I was a bit confused is  because the doctor's office wants to use CPT 11008 for removal of mesh, because he says there wasn't any recurrent hernias just mainly a painful mesh???

See op report below, so I'm probably going to go with 49520 or 49521? 


Procedure:
A typical mesh was found.  This was a combined properitoneal and onlay mesh.  pain was on the medial aspect of the repair close to the pubic tubercle.  There was both onlay mesh in this area as well as properitoneal mesh.

an incision was made through the prior right inguinal incision taken down through the skin and subcutaneous tissue to the external oblique fascia.  The spermatic cord was identified.  It was mobilized and preserved with a penrose drain retracting it.  The external oblique was then incised and beneath it htere was mesh.  This was with difficulty moblized both beneath the cord inferiorly down to the pubic tubercle area and then up and around the cord most very possibly that may have been a nerve entrapping in  this area and appeared to be small nerves such as the ilioinguinal nerve was preseed.  We then mobilized circumfernetially with rather TDS dissection remove the palpable mesh.  Beneath the transversalis fascia on the medial portion of the wound, where he had tenderness, there was also properitoneal mesh.  The transversalis was incised.  The mesh was slowly and circumferentially dissected free.  There may have been a small portion properitoneally near the right femoral artery and vein was left beyond deepened the tissues and unlikely to be the source of any problem, but was felt to dissected off the artery and the vein would have been damaged.  With the mesh complettely removed, a cooper's ligament type repair was carried out approximating the conjoint tendon tissues to the cooper's ligament and the shelving edge of cooper's ligament and the opening for the internal ring admitted a small fingerbreadth in a modified ferguson type technique.  We then approximated the medial ring of the external oblique to the cooper's ligament leaving the cord inferiorly in the subcutaneous position.  All areas including the pubic tubercle, conjoint tendon, inguinal ligament, and the area for the eminence of the ilioinguinal and iliohypogastric nerves were infiltrated with .5% Marcaine.


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## preserene (Jan 11, 2011)

Yes it is a complex  scenerio.
What I infer from the Op note is this; There was pain and deeper tissues , blood vessel involvement in the previous site of hernia along with the mesh incarcerated . As for the recurrence part of it, though there was not a recurrent hernia finally, all the steps for a hernia repair -coopers ligament approach by Fergusson technique (in that way a hernia repair and reinforcement was necessitated  for avoidance of recurrence in the future.)  And the procedure was performed and happened.
So the procedure done deserves the code  49520 if not 49521. (some may argue that there was not an incarceration of a sac or abdominal contents or viscera. So it (49521)may  be under debate or get denied ). Again, if no documented term "incarcerated' recurrent hernia, we can not.

Since the suspected condition of recurrent hernia was not found, I feel you would have to give a diagnosis of  V 71 series as well and the Physician's report of the whole procedure  supported with the diagnosis would be needed. Again make sure there was a ground of  pre-op diagnosis of recurrent hernia. 
Does this help you anyway?


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## BFAITHFUL (Jan 12, 2011)

So what you're saying is that I can probably go with 49520 because there was a repair done, but can't use the diagnosis of recurrent hernia since it's not stated? the path. report states painful right inguinal mesh only.

Thank you so much for your help!


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