Gastroenterology Coding Alert

Question: CPT^® requires modifier 50 or a laterality modifier for epigastric hernias coded to 49570 or 49572. However, I’m trying to code one midline epigastric procedure, as confirmed by two of my doctors, and they didn’t understand why I was asking about the hernia being on the right or left side. How should I code the procedure?

California Subscriber

Answer: In the above scenario, the doctors performed the repair on a midline epigastric hernia. However, 49570 (Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure)) and 49572 (Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated) are not the correct codes to choose from.

Here’s why.

Codes 49570 and 49572 refer to unilateral repair procedures, which means there is one hernia on either the right or left side. This is why CPT^® requires you append modifier LT (Left side) or RT (Right side). Modifier 50 (Bilateral procedure) is required only if there is a hernia on each side. The use of modifier 50 would result in payment for two procedures. The doctors have confirmed this is one hernia in the midline, which means it is located around the vertical center of the abdomen. They’ve also confirmed it is epigastric. Epigastric hernias in the midline are a type of ventral hernia, which means you’ll need to look for a ventral hernia procedure code, most likely 49560 (Repair initial incisional or ventral hernia; reducible) or 49652 (Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible).

To code this accurately though, you’ll need more information. We don’t know whether the surgery was open or laparoscopic, and we don’t know the clinical presentation or whether the hernia’s been previously repaired. Be sure to query the provider anytime the notes are incomplete or otherwise unclear. Generally, you’ll turn to codes 49650-49659 for laparoscopic procedures, and 49491-49611 for open hernia repair. There are many hernia codes, so the more detailed the documentation to support the correct one, the better.

Note: You’ll need to pair the CPT^® code with the correct ICD-10-CM code. For the best fit, look to using a K43.- (Ventral hernia) code such as K43.9 (Ventral hernia without obstruction or gangrene), which includes epigastric hernia and ventral hernia NOS; K43.6 (other and unspecified ventral hernia with obstruction, without gangrene); or K43.7 (Other and unspecified ventral hernia with gangrene), which includes any condition listed under K43.6 that is specified as gangrenous.