# 49650 vs 49659



## maine4me (Oct 31, 2013)

Would someone please review this operative report?  I coded it as 49659 since what was thought to be an inguinal hernia turned out to be femoral.  There is no laparoscopic code for femoral hernia repair.  The doctor still feels the right code si 49650.  

PREOPERATIVE DIAGNOSIS:  Recurrent right groin hernia, possible femoral hernia. 

POSTOPERATIVE DIAGNOSIS: Right femoral hernia. 

OPERATION: Laparoscopic repair right femoral hernia with Physiomesh. 

SURGEON: Dr. Lewis Gill

ASSISTANT: Kelly Williamson, PA-C. 

ANESTHESIA: General. 

PROCEDURE AND FINDINGS:  The patient was brought to the Operating Room, properly
identified, placed on the table in a supine position. Preop diagnosis, procedure and site
were confirmed on time out. He had a gram of IV Ancef preop. General anesthesia was
induced via IV and orotracheal tube. Foley catheter was inserted. The abdomen was widely
prepped with ChloraPrep and after 3 minutes drapes applied. The bed was placed head down
and a small incision made beneath the umbilicus and the Veress needle used to insufflate
the abdomen to 14 mmHg. The 2 lateral 11 mm trocars were inserted through small incisions
under direct vision of the laparoscope. The pelvis was scanned. There were signs of
probable Prolene mesh in the left groin without sign of recurrence. On the right side,
the Ultrapro plug could be seen at the internal ring. There did appear to be a hernia
closer to the direct space. The peritoneum was then incised, there was definite adherence
to the previous mesh. The cord structures were able to be mobilized and then the
preperitoneal space was developed and Cooper's ligament was identified and at this point
it was noted that indeed there was a femoral hernia going out above Cooper's ligament
below the inguinal ligament. The external iliac/femoral vein was clearly evident lateral
to the hernia defect. Because of the difficulty with stripping the peritoneum adequately,
it was elected to use a piece of Physiomesh as the peritoneum would not be able to be
closed over the mesh. This was fashioned and anchored to the pubic tubercle and Cooper's
ligament down far as possible without doing any injury to the vein and anchored to the
transversalis and inguinal ligament superiorly and it was slit to allow the cord to exit
and then overlapped laterally. This was tacked and completed with the Protacker. No tacks
were placed from approximately the 4 o'clock to 8 o'clock position to avoid injury to
nerves and vessels and cord structures. It was elected to use another piece of mesh to
reinforce this and also get better overlapped laterally, lateral to the internal ring and
cord structures. This was also secured with Protacker. At the end, the hernia defect was
nicely covered, there was no bleeding. A wound closure needle with an 0 Vicryl was used
to close the fascia at the two 11 mm port sites. There was no bleeding at these sites and
gas was evacuated from the umbilical trocar and it was removed. Needle, sponge, and
instrument count was correct and blood loss was minimal. Foley catheter was removed, the
patient was reversed and taken to PACU in stable condition breathing on his own.


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## koatsj (Nov 5, 2013)

I had the same issue where the doctor thought it was an inguinal hernia and it turned out to be a femoral hernia that was repaired laparoscopically. I had to use the unlisted code and the billers are still fighting with the insurance company to get payment. We had to send the operative report because the insurance company didn't like my unlisted code. Unfortunately, there is no other code to use


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## BEARDOG (Nov 11, 2013)

koatsj said:


> I had the same issue where the doctor thought it was an inguinal hernia and it turned out to be a femoral hernia that was repaired laparoscopically. I had to use the unlisted code and the billers are still fighting with the insurance company to get payment. We had to send the operative report because the insurance company didn't like my unlisted code. Unfortunately, there is no other code to use



I have to agree, there is no laparoscopic femoral hernia repair code, only for an open femoral hernia and you are correct to use the unlisted code.  Unfourtunately the laparoscopic coding has always  lagged behing the the current technology. 
Sorry!


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