Anesthesia Coding Alert

Question: I'm coding for the surgeon and anesthesiologist (separate claims) for a procedure to repair an initial ventral hernia, which the physician's notes indicate as reducible. First, I need to know the correct way to code for the anesthesiologist's participation in the procedure. Second, a few days after the hernia repair was performed, the patient developed an infection at the incision site and visited the office. The surgeon inspected and opened the wound to drain the infection. She also changed the dressings and administered antibiotics. How should all of this be coded?

New Hampshire Subscriber

Answer: You can report the surgical procedure using 49560 (Repair initial incisional or ventral hernia; reducible). You may need some extra details to choose the appropriate anesthesia code, though.

Your search for the most appropriate anesthesia code will start by determining, either through the operative report or clinical confirmation from the physician, whether the procedure was in the upper or lower abdomen. If the procedure was in the lower abdomen, the correct anesthesia code will be 00832 (Anesthesia for hernia repairs in lower abdomen; ventral and incisional hernias) with a base value of six units.

If the procedure was in the upper abdomen, the accurate choice will be 00752 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) with a base value of seven units.

The follow-up visit: Per CPT guidelines, you can report an E/M service, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

Why you'll use modifier 24: The modifier indicates that the service is not included in the initial surgery's global fee.

On to ICD-9: For the diagnosis, the correct code for the patient's hernia surgery is 553.20 (Ventral hernia, unspecified). For the follow-up visit, choose the appropriate infection code, such as 998.59 (Other postoperative infection).

Caution: Different payers have different rules for what they include in the global surgical package. Follow your payer's rules on whether you may report the follow-up visit separately.