General Surgery Coding Alert

There are many different hernia repair procedures, and using the correct CPT and diagnosis codes when billing for such services can be quite complicated for surgeons and their office staff. But once they understand the correct codes, practices can receive proper reimbursement.

Is it Ventral, Epigastric or Umbilical?

It is common for the surgeon to submit the following documentation in the op report about a hernia repair to his office staff:

1. Preoperative diagnosis: Epigastric hernia
2. Postoperative diagnosis: Epigastric hernia
3. Procedure: Repair of ventral
hernia with insertion of marlex mesh

For the surgeon, there is no conflict between the pre- and postoperative diagnoses and the procedure because, clinically speaking, a ventral hernia is defined as any hernia of the abdominal wall other than one that is inguinal or femoral. Using this definition, the procedure qualifies as a ventral hernia, even though the documentation for both pre- and postop diagnoses clearly states otherwise. (For more information on hernia, see box on page 27.)

But for billing, such a report poses significant problems for the coder, beginning with the fact that CPT 1999 specifically differentiates among a number of herniae repair that could clinically be defined as ventral, listing more than 20 specific abdominal wall hernia repair procedure codes. Furthermore, Medicare has assigned varying relative value units (RVUs) to the procedures, which makes it even more important to use the right code so you can be paid correctly.

It would be very easy to code all abdominal herniae other than inguinal or femoral with ventral hernia codes (49560-49566; for definition, see box on page 27) based on the clinical definition, but the codes need to be based solely on the documentation in the operative report, says Kathleen Mueller, RN, CPC, CCS-P, a registered nurse and reimbursement and coding specialist in the office of Allan L. Liefer, MD, a general surgeon in Chester, IL. The operative report referred to above, Mueller says, clearly indicates that the procedure should be coded as an epigastric hernia (49570-49572), since the diagnosis code of epigastric hernia would not match the repair of ventral hernia.

Billing for Mesh Application

1. Insertion: The insertion of the marlex mesh poses another problem, says Stephanie Albright, CPC, CPC-H, a general surgery coding specialist with Coding Strategies Inc. of Dallas, GA. She notes that 49568 (implantation of mesh or other prosthesis for incisional or ventral hernia repair [list separately in addition to code for the incisional or ventral hernia repair]) clearly states the procedure is an add-on code that can be listed only for ventral, or incisional, hernia procedures. If, however, the surgeon repairs an epigastric or umbilical hernia, mesh implantation cannot be billed separately, because it is considered an aid to the repair.

Similarly, says Mueller, If the operative report states repair of umbilical hernia with marlex mesh, you cannot code the procedure as a repair of ventral hernia, because the report does not say ventral. And the mesh is not separately billable because implantation of mesh may only be billed as an add on to 49560-49566.

Note: Because 49568 is an add-on code, it will be reimbursed at 100 percent and should not be billed with modifier -51 (multiple procedures).

2. Modifier -22: Nor can modifier -22 (unusual procedural services) be added to the primary (umbilical or epigastric) hernia repair just because you implant mesh. According to Mueller, Medicare bulletins have repeatedly stated that modifier -22 may not be added to umbilical, epigastric, femoral or inguinal hernia repairs for regular mesh placement. However, she notes that the -22 modifier can be added if the repair took significant time and effort over and above the regular placement of mesh.

Of course, your operative report needs to show why it took so much time, Mueller says, adding that the explanation should be written very simply. Keep in mind that not all review personnel at the insurance carriers have the same knowledge of medical terminology as physicians. Therefore, the documentation to support modifier -22 should be easy to understand, so that anyone reading the report knows why it took so much longer for the repair.

Mueller suggests the documentation supporting modifier -22 might read as follows: This was a very large hernia. It took me an extra two hours to complete this hernia repair because the patients ballooned sac extended from the hole in the groin to the knee. Normally, it takes me one hour to complete the repair.

By describing the rationale for attaching modifier -22 in this way, you have painted a mental image that is easy to understand even for someone who doesnt know what a hernia is, and that, she says, is the key to getting reimbursed for the extra time it may take to attach the mesh.

Mueller suggests that the documentation be included in the op report, since a hard copy of the report is always required by the carrier when you are submitting a claim with modifier -22. However, if the op report does not state the reason for the increased difficulty in simple laymans terms, a cover letter should be attached to support it, she says.

Use Caution When Choosing
Precertification Diagnosis Code

When the general surgeon sees a patient in the office who has had previous abdominal surgery and appears to have a hernia around the area of the umbilicus, great care must be taken in obtaining precertification for any procedure that may follow, Mueller says, noting that often what appeared to be an umbilical hernia in the office turns out to be an incisional or ventral hernia in surgery.

This can pose a reimbursement problem, because if the surgeon placed a piece of mesh over what turned out to be a ventral hernia repair and documents it that way, but the office procedure was precertified as umbilical, the documentation does not match and the claim may be denied. In that situation, you would have to call the insurance carrier on the day of surgery to update the precertification. According to Mueller, some carriers will allow a 48-hour window, and some will not.

I usually instruct physicians to document an umbilical hernia during the first encounter only if they are 100 percent sure; otherwise, they should document as ventral hernia since most carriers will not deny a claim if a lesser procedure (i.e., one with fewer RVUs) is submitted later (i.e., the umbilical has a lesser RVU than the ventral), she says. If the surgeon goes into surgery and finds umbilical hernia but had previously pre-certified a ventral hernia, the op report should read as follows:

Pre-op Dx: Ventral hernia.
Post-op Dx: Umbilical hernia.
Procedure: Repair of umbilical hernia.

Note: The procedure would be billed as 49585 (repair umbilical hernia, age 5 years or over; reducible).