General Surgery Coding Alert

Question: Our surgeons are using a laparoscopic technique for incisional hernia repairs, but we are continuously getting denials for these procedures. One insurance company even stated that we needed a more specific code before they would consider reimbursement.

We are using 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy). Is there any other code that we can use or any tips on getting this procedure covered?

Louisiana Subscriber

Answer: Your coding in this case appears to be correct and is supported by CPT and CMS guidelines, which specifically instruct providers to use an unlisted- procedure code when no available code describes the specific procedure your surgeon performs.

The AMA edition of CPT 2007, for instance, states, -A service or procedure may be provided that is not listed in this edition of the CPT codebook. When reporting such a service, the appropriate -Unlisted Procedure- code may be used to indicate the service ..."

More specifically, proper coding practice dictates that if the surgeon performs a laparoscopic procedure and there is no laparoscopic code, you should use the unlisted-procedure code for that body area. You should not use a comparable open code.

Tip: If you want to gain appropriate payment for an unlisted-procedure claim, include documentation to compare the reported unlisted procedure to the next closest procedure that appears in CPT. Specifically, codes for reporting traditional/open repair of ventral/incisional hernias include 49560 (Repair initial incisional or ventral hernia; reducible), 49561 (.. incarcerated or strangulated), 49565 (Repair recurrent incisional or ventral hernia; reducible) and 49566 (.. incarcerated or strangulated).

Laparoscopic repair differs from traditional, or open, repair in that the surgeon places the mesh from inside the abdomen rather than from outside. Consequently, this procedure is more difficult and takes more time (although outcomes for patients are typically improved).

When you-re filling out the claim form for the laparoscopic hernia repair, explain why the doctor took a laparoscopic approach rather than a traditional (open) one. You should also indicate the size of the hernia because surgeons typically perform laparoscopic repair on complex hernias bigger than 3 cm.

Remember to note the following in the medical record to show that the laparoscopic repair is justified: the patient's history of hernia repair, a short description of the surgery, whether the hernia under repair is unilateral or bilateral, whether it's reducible or incarcerated/strangulated, and how the doctor uses the mesh.

Your payer may justify noncoverage if it determines a procedure is -unproven- or not medically necessary, for instance, but it shouldn't reject the claim based solely on the fact that you are reporting an unlisted-procedure code, and you have grounds for an appeal in this case.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, charge capture manager for the University of Washington Physicians.