Practice Management Alert

Question: A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59?

Mississippi Subscriber

Answer: You might think you can append modifier 59 (Distinct procedural service) to the hernia repair code and bill it separately. After all, the hernia repair seems to qualify as a different reason for surgery than the colectomy -- for example, if the patient has a recurrent hernia. But modifier 59 tells the payer the hernia repair happened at a separate session, which isn't true in your case.

If the physician's documentation proves justification, you might try appending modifier 22 (Unusual procedural services) to the colectomy code because of the extra complexity, time, and effort required by the complex hernia repair with mesh.

The Correct Coding Initiative (CCI) considers hernia repair code 49561 (Repair initial incisional or ventral hernia; incarcerated or strangulated) to be part of partial colectomy code 44140 (Colectomy, partial; with anastomosis) because the hernia repair is integral to the closure. You may have to appeal for the additional money.

So make sure the documentation supports the additional substantial complexity of the hernia repair and mesh implantation before appending modifier 22.

-- The answers to the Reader Questions and You Be the Billing Expert were provided or reviewed by Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J., and senior coder and auditor for The Coding Network, and/or by Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.