# Large Incisional Hernia



## hpierce (Mar 29, 2012)

can anyone help?? I know that I would code the 49560 & 49568 for the incisional hernia repair, but would I need additional codes for the excision of the scar (I'm leaning towards included) and the "subperitoneal flaps"??? 

PREOPERATIVE DIAGNOSIS: Large incisional hernia.
POSTOPERATIVE DIAGNOSIS: Large incisional hernia.
PROCEDURE AND FINDINGS: 
Surgical reduction and repair of a large incisional hernia (15 x 25 cm) repair with 25 x 33 cm UltraLite mesh (with Seprafilm coating) ina an underlay mesh technique with at least 5cm underlay in all directions. The overall dissection was ultimately not as difficult as expected but still tedious and several hours. We excised segment of redundant extensively scarred midline skin with primary wound closure, placement of drains.
BRIEF HISTORY: This is an 80-year-old female who had a very complicated case close to about one year ago with a combination of postoperative bleeding, wound complications, etc.  She ultimately all healed in but has developed a very large incisional hernia.  This is repaired at this time.
DESCRIPTION OF PROCEDURE: After adequate endotracheal general anesthesia obtained, a Foley catheter was placed.  The abdomen was prepped with ChloraPrep solution and draped sterilely. Midline incision was carefully entered at one spot superiorly and we were able to gradually peel off the omentum and bowel from the midline wound without difficulty until we got all the way everything freed up from subxiphoid to pubis.  There is only one area of a small serosal tear on the small bowel, which was sutured with interrupted Lembert sutures of 3-0 Vicryl and even that was rather a very small area. We have mobilized the subperitoneal flaps widely 5-10 cm in all directions.  The ultimate size of the defect is about 15 x 20 cm. Ultimately, we used a 25 x 33 cm UltraLite oval mesh. We put this in then in a transverse manner, we trimmed the mesh slightly for the proper fit. We now secured the mesh in place with horizontal mattress sutures, using #1 Prolene on XLH needle through peritoneum , muscle and fascia   initially placing the North, South, East and West positions. We then placed another #1 Prolene at each of the points of the compass between the initial two for a total of eight sutures placed.  We then placed an additional two to three sutures for each of the paired sutures until a total of 16-20 sutures are in place. As we carefully pull up on these, we find the good fit with a smooth contour of the mesh.  There is no gaps.  These were all tied down. Next, we carefully used some 3-0 Vicryl interrupted to circumferentially tack the edges of the defect itself to the mesh, making an inner attachment to the mesh. Next, we copiously irrigated with antibiotic irrigation. Next, it was necessary to excise some of the redundant skin as it was mostly scar and it was ischemic.  We marked the area along the edge where it seems to be obvious ischemic and then lifting up on this there was plenty of access and it actually exactly duplicates the area that we have already marked.  So, we excised that then we excised the redundant skin and the area of ischemic skin with scalpel and then hemostasis with the cautery. We closed this and we got a very nice flat skin closure without tension.
First, we placed a number of subcuticular 3-0 Vicryl's and then  placed the large and small proximate staples on the skin.  Sterile dressing applied.  Note that we have placed two 15 mm round Blake drains and these were secured in place using Prolene suture. Sterile dressing was applied to complete the procedure. Estimated blood loss was 100 cc.  She tolerated the procedure well.  She was extubated and left the operating room in stable condition.

Thanks!
Heather, CPC


----------



## colorectal surgeon (Mar 29, 2012)

Since the skin had to be excised in order to repair the hernia, it can't be coded separately if I'm correct.  

Thoughts anyone?


----------



## hpierce (Mar 30, 2012)

colorectal surgeon said:


> Since the skin had to be excised in order to repair the hernia, it can't be coded separately if I'm correct.
> 
> Thoughts anyone?



And how about the flaps? Could we bill separately for that?

Thanks,
Heather


----------



## colorectal surgeon (Apr 1, 2012)

I'm not sure about that one.  Thoughts anyone? I think no, unfortunately?


----------



## FTessaBartels (Apr 3, 2012)

*Hernia repair only*

I agree with colorectal surgeon .... the scar excision and flaps will be included with the hernia repair.

However ...  I would listen to arguments that this deserves a -22 modifier.  

Hope that helps.

F Tessa Bartels, CPC, CEMC


----------



## Torilinne (Apr 3, 2012)

I would agree with the use of a -22 modifier based on the provider's documentation that the op was tedious and took several hours, along with the excision of scar/skin.  That excision of skin was definitely above and beyond the norm for a hernia repair.  I'd also agree with not being able to code separately for the skin flaps.....

V Davis CPC, CGIC


----------



## colorectal surgeon (Apr 3, 2012)

I would definitely agree with the 22 modifier.  I think it can easily be justified with the additional work


----------



## hpierce (Apr 4, 2012)

Thanks for all the responses!! I love utilizing this site!!

Heather, CPC


----------

