Gastroenterology Coding Alert

Question: I am billing 49505 and +49568 together and some payers are paying and others are not. Medicare is paying. What can I do about the other payers that are following CPT's rules?

Georgia Subscriber

Answer: This is incorrect billing, even if you are getting paid by some payers. You should immediately stop billing 49505 and +49568 together. In fact, you should also refund the carriers that paid you for these codes together.

Why? The hernia types don't match up. Add-on code +49568 (Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection [List separately in addition to code for the incisional or ventral hernia repair]) is for incisional and/or ventral hernia repairs only.

Code 49505 (Repair initial inguinal hernia, age 5 years or older; reducible) describes a reducible hernia. Therefore, you should never be billing +49568 with 49505. Surgeons often will place prosthetic mesh to facilitate hernia repair, but you can report +49568 separately only when the surgeon repairs an incisional/ventral hernia (49560, 49561, 49565, 49566). For all other hernia repairs (epigastric, umbilical, etc., open or laparoscopic), you cannot claim +49568, even if the surgeon places mesh during the repair.

In addition: You would not use the mesh code (+49568) with the new laparoscopic hernia codes:

• 49652 -- Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia (includes mesh insertion, when performed); reducible

• 49653 -- ... incarcerated or strangulated

• 49654 -- ... Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible

• 49655 -- ... incarcerated or strangulated

• 49656 -- Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible

• 49657 -- ... incarcerated or strangulated.

These codes state mesh is included. Reporting +49568 would be double billing for the mesh.