General Surgery Coding Alert

Question: We-ve had a rash of infected mesh cases recently, and our physicians want to report 49568 for this. But this is an add-on code, and we cannot report it alone. Some folks in the office have suggested reporting a recurrent hernia repair in addition so that we can claim 49568. But hernia repair isn't documented, just mesh removal and replacement. How should we report these procedures?

Arizona Subscriber

Answer: First, you must never code for anything that the surgeon didn't actually do or that documentation cannot substantiate. Filing false claims can cost your practice triple damages in paybacks (in other words, you-ll have to pay back three times what you received in payments), plus thousands of dollars in fines for each instance of improper coding. Such coding is not just incorrect -- it is fraudulent and potentially ruinous.

With that in mind, you should not report recurrent hernia repair (such as 49565, Repair recurrent incisional or ventral hernia; reducible) if no diagnosis exists to justify the procedure and/or the surgeon did not perform and note the procedure in his operative report. Simply stated, the repair has to be necessary, completed and documented if you wish to bill it.

You are correct 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]) is an add-on code and as such cannot stand alone. Even if your surgeon only removes and replaces the infected mesh, you cannot report 49568 as the sole or primary procedure.

The solution, therefore, is to rely on an unlisted procedure code. Although you should avoid such -unspecified- coding whenever possible, CPT's -Instructions for Use- clearly state, -Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.- 
 
Your best option is 22999 (Unlisted procedure, abdomen, musculoskeletal system). This is a better choice than 49999 (Unlisted  procedure, abdomen, peritoneum and omentum) because the surgeon won't typically enter only the abdominal wall, not the abdominal sac. Code 22999 is also better than 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy) because no actual hernia is involved.

Note: In most cases, the surgeon would likely forego re-implanting mesh in an infected environment to avoid a re-infection. In this case, an unlisted-procedure code is still the best choice because there is no code to report mesh removal only in these circumstances.

If you deal with these types of claims often, develop a cover letter describing in detail what is done (and why). Compare the procedure to an existing, valued code to provide the payer with reimbursement guidance: Insurers pay much better on unlisted-procedure codes when you make such a comparison, many coding experts say.

Send your claim electronically to prove timely submission and then follow up with a -paper- claim. Include the cover letter and operative note with your submission and note on the CMS-1500 claim form -documentation copy, already sent electronically, not a duplicate claim.-