Wiki Help with bundling issue

[Coastal Coder]

I have the attached op note for a incarcerated umbilical hernia repair w/ a small bowel perforation. I coded it as 49587. My physicians wants to also charge for the repair of perforation. To me that would be bundled, am I over thinking this? Can I charge for both and if so what code would I add?
Thanks so much for any help with this.

PROCEDURE:
Repair of incarcerated umbilical hernia and repair of small-bowel perforation.
ANESTHESIA:
General.
FINDINGS:
Incarcerated small bowel with some ischemic changes but no frank necrosis. Small area of perforation at the
level that the small bowel exited the fascia.
DESCRIPTION OF PROCEDURE:
Patient was brought to the OR table. She was placed in supine position. General anesthesia was induced. She
was prepped and draped in standard fashion. A transverse infraumbilical incision was made. This was carried
down through the subcutaneous tissue. The umbilical stalk was taken off the level of the fascia. The hernia sac
was dissected out circumferentially and hernia sac was then opened and the small bowel examined. We were unable
to further eviscerate the small bowel due to the small fascial defect. At that point the fascial defect was
enlarged by 1 cm medially. The small bowel was run, partially eviscerated and examined. The incarcerated small
bowel was purplish consistent with transient ischemia, but there was no frank necrosis. Once it had been
released from the fascia, it began to pink up. A small perforation was noted where the small bowel had
previously exited the fascia. This was repaired in 2 layers with 3-0 Vicryl suture. The small bowel was then
dunked back into the abdomen. The hernia sac was excised and the fascial defect was closed with several
interrupted #1 PDS sutures. The umbilical stalk was then tacked back down to the fascia. The subcutaneous
tissue was closed and the skin was closed with 4-0 Monocryl. Dressing was applied. Patient tolerated the
procedure well and was transferred to PACU after extubation.

 

[jjhamer1]

Was surgeon aware of the small bowel perforation, prior to performing surgery?
(perforation may have been caused intraoperatively?)
If not, this is an incidental finding, and cannot be billed. You still definitely need to code the Dx "perforation of small bowel"...but do not code the repair which would be 44602.

 

[CodingKing]

Per the NCCI Manual:

If a CPT code descriptor includes the term “separate procedure”, the CPT code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the separate reporting of a “separate procedure” when performed with another procedure in an anatomically related region often through the same skin incision, orifice, or surgical approach.

I know both the perf repair and the hernia repair both say (Separate Procedure) but the concept only applies to one of them. The reason is an incidental hernia repair is bundled into other higher value procedures in the same anatomically related area

 

[Coastal Coder]

Thank you so much for your help, I thought this was a bundled procedure but having trouble getting my physician to believe me. This will help me a lot.