Gastroenterology Coding Alert

Find out what your provider needs to document for reimbursement.

As you probably know, several CPT^® hernia repair codes got the axe on January 1, 2023, and several new codes took their place. Over the last few months, you’ve been getting used to the changes but if you’re like many coders, you still have questions.

Here, we’ll run through the new anterior abdominal hernia repair codes, including their significance, and outline what documentation your providers need to include to ensure accurate and thorough reporting.

Understand What Changed

CPT^® no longer recognizes open hernia repair codes 49560-49566 (Repair … incisional or ventral hernia …), 49570-49572 (Repair epigastric hernia …), 49580-49587 (Repair umbilical hernia …), 49590 (Repair spigelian hernia). The following laparoscopic hernia repair codes are also obsolete: 49652-49653 (Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia …) and 49654-49657 (Laparoscopy, surgical, repair, … incisional hernia …).

To replace these codes, CPT^® created a more unified category that encompasses open or laparoscopic epigastric, incisional, ventral, umbilical, and spigelian hernia repair.

Review the New Codes

For any hernia repair in the new “anterior abdominal hernia” category, you’ll report one of the 12 new codes. CPT^® 2023 distinguishes these 12 new codes based on initial or recurrent, reducible or incarcerated/strangulated, and repair size, as follows:

• 49591 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible)
• 49592 (… less than 3 cm, incarcerated or strangulated)
• 49593 (… 3 cm to 10 cm, reducible)
• 49594 (… 3 cm to 10 cm, incarcerated or strangulated)
• 49595 (… greater than 10 cm, reducible)
• 49596 (… greater than 10 cm, incarcerated or strangulated)
• 49613 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible)
• 49614 (… less than 3 cm, incarcerated or strangulated)
• 49615 (… 3 cm to 10 cm, reducible)
• 49616 (… 3 cm to 10 cm, incarcerated or strangulated)
• 49617 (… greater than 10 cm, reducible)
• 49618 (… greater than 10 cm, incarcerated or strangulated)

Base Coding on Total Defect Size

“These codes [49591-49596, and 49613-49618] are reported only once, based on the total defect size, for however many abdominal hernias the patient has that are getting repaired in that surgical session,” said Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education, Olympia Medical in Livonia, Michigan, in the March 15 AAPC Ask & Learn Webinar titled “2023 Changes for Hernia Coding.”

This is an important point because even if the provider is repairing multiple hernias in the abdominal area, you still only report one incarcerated or strangulated repair code. This is true even with the presence of a reducible hernia. Furthermore, which code you use depends on the total measurement.

How to measure: “You take the farthest two points, and that measurement is what you’re going to base your code on,” said Shew. If there are multiple non-contiguous defects separated by greater than or equal to 10 cm of intact tissue, the defect size is the sum of each individual hernia.

If the patient has one hernia, you’ll simply use the documented measurement of the pre-surgical hernia’s longest length and report the code that best represents that size.

However, let’s say the provider makes an incision in one abdominal area, then makes a separate incision in another area, and the total area is more than 10 cm. “When that happens, you would still only bill one code. If they are within 10 cm of each other, you go from the furthest point to furthest point and use that total length,” said Elizabeth Herbert, RHIA, CPC, CPMA, CRC, CCC, CPC-I, Epic Application Analyst at Baptist Health System in Scottsburg, Indiana during the AAPC Ask & Learn Webinar. If the hernias are more than 10 cm apart, then you measure each hernia then add the lengths together for a total sum.

Example: The provider performs one 2 cm reducible initial incisional hernia repair and two 4 cm incarcerated initial incisional hernia repairs that are 2 cm apart. The total distance between the two farthest parts is 10 cm, which means you’ll report 49594.

Note: Because of nature of the incision itself, you can separately report other types of hernia repair, such as for femoral, lumbar, inguinal, and parastomal hernias if done in the same surgical session, Shew clarified.

Default to the Smallest Size When Documentation is Vague

Total size is required to report the repair accurately. That measurement needs to be determined before the patient is opened “because the fascia can retract during the repair and the measurement would be falsely elevated,” Shew said.

If the provider is vague and documents that the hernia was approximately 3 cm, which is right on the cusp between codes, you will likely need to play it safe and report the code for a hernia that’s less than 3 cm, 49591. Even if you were to query the provider, there’s no way they can measure the pre-surgery hernia size retroactively. The same rings true if the provider did not report a measurement at all. You’ll have to report the lowest code possible, which again would be 49591.

Note: This scenario offers the perfect opportunity to initiate an educational conversation. Providers are always going to want to get paid fairly, and that’s only possible with exact measurements.

Recognize the Coding Impact of the 0-Day Global Period

Another thing that changed in 2023 is that now these codes have zero global days. “This means that any follow up that needs to be done afterward can be billed separately,” Shew said.

For example, if a patient stays one night and is discharged the following day, you can report 99238 (Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter) or 99239 (… more than 30 minutes…) for the day following the procedure. If the provider cared for the patient for 5 hospital days, they can now report an inpatient evaluation and management (E/M) code for each day the patient was seen.

A 0-day global period also means that you can separately report any simple follow-up services, such as wound debridement or suture removal that are done in the office. All in all, this makes coding considerably easier. You don’t have to track any additional services, making the tracking and reimbursement processes less complex when compared to procedures that have longer global periods.