General Surgery Coding Alert

49568 isn't the answer, AMA says

In July, General Surgery Coding Alert reported that when the surgeon uses AlloDerm (human regenerative tissue) instead of mesh for ventral hernia repair, you may consider the AlloDerm to be a prosthesis and therefore report +49568 (Implantation of mesh or other prosthesis for incisional ventral hernia repair [list separately in addition to code for the incisional or ventral hernia repair]) for its use (see -Mesh Isn't the Only Prosthesis for Hernia Repair- later in this issue).

But the AMA recently suggested that another code is better suited for this purpose.

Look to an Unlisted-Procedure Code

According to the AMA, if the surgeon documents using AlloDerm in the place of mesh to reinforce ventral hernia repair, you should report unlisted-procedure code 17999 (Unlisted procedure, skin, mucous membrane and subcutaneous tissue).

-I questioned the AMA about this, and they responded that 15330-15331 [Acellular dermal allograft, trunk, arms, legs -], specifically, are not appropriate for AlloDerm when used for repair of fascia/abdominal wall,- says Carrie Young, CPC, coding unit trainer/supervisor at Springfield Clinic LLC in Springfield, Ill. -They recommended 17999 instead.-

Similarly, -Medicare [specifically, Illinois Part B Carrier Wisconsin Physician Services, or WPS]commented that 49568 -does not appear to correspond with the description for AlloDerm,- - Young says.

Bottom line: Although AlloDerm may technically function as a prosthesis when used during hernia repair -- and although not all Medicare carriers may follow WPS's lead -- the AMA's comments bolster the claim that 17999, rather than 49568 or 15330-15331, is the best choice under these circumstances.

49568 Still Represents a Good -Comparison Code-

Young's query to the AMA may reveal that you should report 17999 rather than 49568 for AlloDerm for fascia/abdominal wall repair, but 49568 can still act as a benchmark for the physician effort for repairs of this type.

Background: Insurers determine payment for unlisted-procedure claims by reading your procedure description and comparing it to a similar, listed procedure with an established reimbursement value, says Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.

But -if you let the insurer choose the -comparison- code for you, you could end up having to fight it later. For instance, the payer might compare your claim to something alued much lower than the unlisted procedure that you performed,- Corcoran says.

Take charge of your claim: Rather than allow the insurer to determine which is the -next closest- code on which it should base your payment, you should explicitly reference the nearest equivalent listed procedure in your explanatory note. In this case, 49568 provides a near-perfect approximation of the work involved in placing AlloDerm during ventral hernia repair.

Unlisted-Procedure Code May Face Restrictions Like 49568

You may report 49568 separately only when the surgeon performs the following incisional or ventral hernia procedures:

- 49560 -- Repair initial incisional or ventral hernia; reducible

- 49561 -- ... incarcerated or strangulated

- 49565 --  Repair recurrent incisional or ventral hernia; reducible

- 49566 -- ... incarcerated or strangulated.

For any other hernia repairs -- including epigastric, umbilical, spigelian and inguinal hernia repairs (49570-49651) -- you may not report 49568 separately. The National Correct Coding Initiative (NCCI) recently solidified this guideline by bundling 49568 into all hernia repairs (49570-49651).

Keep in mind that although NCCI doesn't bundle 17999 into hernia repairs (49570-49651), most payers probably won't want to pay separately for AlloDerm placement with these repairs any more than they would want to pay for placement of mesh (49568).

Take-away advice: Check with your payer before reporting 17999 for using AlloDerm during epigastric, umbilical, spigelian and inguinal hernia repairs.