Gastroenterology Coding Alert

Question: A surgeon worked on a patient to repair a reducible umbilical hernia. During the procedure, she finds a sizeable gallstone embedded in the omentum extending into the preperitoneal fat. The surgeon excises the gallstone granuloma with cautery.

Patient history indicates cholecystectomy eight years ago. What ICD-9 and CPT codes should I bill?

New York Subscriber

Answer: You should code 49585 (Repair umbilical hernia, age 5 years or older; reducible). If the gallstone resection represents a significant amount of extra time and effort, then append modifier 22 (Increased procedural services).

Careful: You're risking a denial if you report the omentum gallstone resection (49255, Omentectomy, epiploectomy, resection of omentum [separate procedure]) in addition to the 49585 hernia repair. Why? As a designated "separate procedure" code, you should only list 49255 if it is the only procedure the surgeon performs at the site. Similarly, you should not report the service as a peritoneal foreign body removal (49402, Removal of peritoneal foreign body from peritoneal cavity) because you indicate that the gallstone is imbedded in the omentum and extends only partially into the peritoneum.

Check the documentation before you decide on a diagnosis code. ICD-9 568.9 (Unspecified disorder of peritoneum) is your best bet. However, if the surgeon indicates that he thinks the gallstone  s as dropped and left in the omentum during the previous surgery, you should consider it a foreign body left during surgery and code 998.4 (Foreign body accidentally left during a procedure). You should report the umbilical hernia as 553.1 (Umbilical hernia).