The following operative report came across my desk and the surgeon wanted to bill 49520-22 with 20780 for the removal of the mesh. My first response was that 20780 is not an appropriate code for mesh removal. I was forwarded the attached article that says that 20780 can be billed for removal of mesh if it is not infected. I had never heard of this before and question if this is correct because 20780 is for removal of hardware and doesn't indicate anything in regards to mesh. However, 20780 wouldn't be billable in this case anyway because the mesh IS infected. I don't think we can bill the 11005 and 10080 because it isn't debridement of necrotizing soft tissue and 10180 wouldn't be supported either. I think the 49520-22 is the only code that can be billed unless we were to go with 49999 but I have no idea what the comparable code would be if that's the case. Any advice would be greatly appreciated.
XXXXXXXXXXX has had a significant problem with chronic groin pain on the left side. He had
a sports hernia repaired followed by another repair. He has had some significant drainage from
this area and it is my presumption that he has a mesh infection. He is brought to the operating
room for an excision of all of the mesh.
Pre- and postoperative diagnosis. Chronic groin pain, Pre- mesh infection
Procedure. Excision of foreign body, repair of left inguinal hernia, excision of cutaneous sinus
tracts ×2
Findings. The patient had significant ingrowth of the 2 meshes that were placed. I was able to
remove all of the mesh and all of the prior sutures. This did require an extensive dissection.
Cultures were also obtained. I did excise the sinus tracts as well.
Procedure in detail. The patient was brought to the operating room placed in supine position the
operative table and underwent general endotracheal anesthesia per the issue problems such
with a prepped and draped in routine fashion expose his left groin. I then reopen his old incision
and extended this medially. This was a very difficult dissection requiring at least an hour and a
half to get through all of the adhesions. The mesh onlay was first identified and then dissected
all of this free stent to the pubic tubercle and all of the area that was covered by this mesh.
Several small Prolene sutures were identified and removed.
The external oblique was also identified and dissected free the underlying mesh was also
identified and excised. This was also a very tedious dissection. I was able to ultimately identify
the pubic tubercle and encircled his cord structures with a Penrose drain. There was no
evidence of division of any of the cord the but the dissection of this area was quite difficult and I
do have a concern of the possibility of ischemic orchitis.
Once all of the mesh and sutures were excised there was some defect in the external oblique as
well.
The posterior floor of the inguinal canal was also opened during all of this dissection. This was
unavoidable due to the extensive adhesions and the mesh placement itself.
In an effort to diminish the possibility of a recurrence I then placed the Phasix plug into the
preperitoneal space and opened it up. This was then fixed to the internal oblique which I
plicated down to the reflected portion of the inguinal ligament in a similar manner to a Bassini
repair. 2-0 PDS suture was used. An onlay of the Phasix mesh was then placed on top of this
entire inguinal floor and secured with interrupted 2-0 PDS as well
Another suture of P DS 2 oh was used to then closed the external oblique. There were several
areas of deficits in tissue of the external oblique so some of the Phasix was uncovered and
touching the subcutaneous layer.
XXXXXXXXXXX has had a significant problem with chronic groin pain on the left side. He had
a sports hernia repaired followed by another repair. He has had some significant drainage from
this area and it is my presumption that he has a mesh infection. He is brought to the operating
room for an excision of all of the mesh.
Pre- and postoperative diagnosis. Chronic groin pain, Pre- mesh infection
Procedure. Excision of foreign body, repair of left inguinal hernia, excision of cutaneous sinus
tracts ×2
Findings. The patient had significant ingrowth of the 2 meshes that were placed. I was able to
remove all of the mesh and all of the prior sutures. This did require an extensive dissection.
Cultures were also obtained. I did excise the sinus tracts as well.
Procedure in detail. The patient was brought to the operating room placed in supine position the
operative table and underwent general endotracheal anesthesia per the issue problems such
with a prepped and draped in routine fashion expose his left groin. I then reopen his old incision
and extended this medially. This was a very difficult dissection requiring at least an hour and a
half to get through all of the adhesions. The mesh onlay was first identified and then dissected
all of this free stent to the pubic tubercle and all of the area that was covered by this mesh.
Several small Prolene sutures were identified and removed.
The external oblique was also identified and dissected free the underlying mesh was also
identified and excised. This was also a very tedious dissection. I was able to ultimately identify
the pubic tubercle and encircled his cord structures with a Penrose drain. There was no
evidence of division of any of the cord the but the dissection of this area was quite difficult and I
do have a concern of the possibility of ischemic orchitis.
Once all of the mesh and sutures were excised there was some defect in the external oblique as
well.
The posterior floor of the inguinal canal was also opened during all of this dissection. This was
unavoidable due to the extensive adhesions and the mesh placement itself.
In an effort to diminish the possibility of a recurrence I then placed the Phasix plug into the
preperitoneal space and opened it up. This was then fixed to the internal oblique which I
plicated down to the reflected portion of the inguinal ligament in a similar manner to a Bassini
repair. 2-0 PDS suture was used. An onlay of the Phasix mesh was then placed on top of this
entire inguinal floor and secured with interrupted 2-0 PDS as well
Another suture of P DS 2 oh was used to then closed the external oblique. There were several
areas of deficits in tissue of the external oblique so some of the Phasix was uncovered and
touching the subcutaneous layer.
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