Coding Hernia Repairs

This edition of “Spotlight on CPT” presents information on coding hernia repairs.  Correctly assigning hernia repair codes requires coders to first determine what type of hernia is being repaired.  A coder must identify if the hernia is inguinal, femoral, incisional, umbilical, ventral, hiatal, etc.  Based on the type of hernia being repaired other factors may need to be considered such as:

• Initial vs. recurrent
• Reducible vs. incarcerated/strangulated/obstructed
• Unilateral vs. bilateral
• Laparoscopic vs. open
• Age
• Mesh usage
• Sliding

To begin, let’s take a deeper look at inguinal hernias.  Determine the approach (open or laparoscopic) of the repair first.  Next, the age of the patient is an important consideration.  There are four age groups that a patient could fall into as noted here:

• Preterm infant (<37 weeks at birth up to 50 weeks postconception age)
• Full term infant (< 6 months of age) or preterm infant (> 50 weeks postconception age but younger than 6 months)
• 6 months to < 5 years
• 5 years and older   

Let’s take just a minute to look at calculating the weeks for preterm infants.  Imagine that an infant was born at 35 weeks of gestational age.  Two months later he is coming in for an inguinal hernia repair.  You would take the 35 weeks and add 8 weeks (two months) to arrive at 43 weeks of postconception age.  This means the codes for this repair will be either 49491 for a reducible hernia or 49492 for an incarcerated hernia.  Now if the same preterm infant was coming in four months after birth you would take the 35 weeks of gestational age at birth and add 16 weeks (4 months) to arrive at 51 weeks postconception age.  The correct category of codes would be 49495-49596 again based on reducibility. 

Once a coding professional knows the correct age group to focus on, a determination must be made as to whether this is the first repair of the hernia or if it is a recurrent repair.  Finally, coders need to identify from the provider documentation if the repair was performed on a reducible or incarcerated hernia.    

A final consideration regarding inguinal hernia repairs is to know if it was considered sliding or not.  A sliding hernia is one that has a retroperitoneal organ protruding into the sac.  When sliding inguinal hernias are repaired, no matter what the age, the code to be assigned is 49525.  If a sliding hernia is described as incarcerated, coders are directed to use the codes for incarcerated hernia repair.

Coders can apply the previous method for coding other hernias as well.  Determine approach, identify initial or recurrent, and consider the reducibility of the hernia in order to assign the appropriate code. Open umbilical hernias are the only other hernia type besides open inguinal where age is a factor. 

An important reminder when coding hernia repairs is that the use of mesh is considered integral to these procedures unless the hernia is incisional or ventral.  When incisional or ventral hernias are repaired with an open method using mesh, assign two codes; one for the hernia repair itself and a second (49568) which is an add-on code for the insertion of the mesh.  However, coding professionals should recognize that if an incisional hernia is repaired laparoscopically, the use of mesh is included in the code (49654 or 49655) and the add-on code should not be reported. 

Now, light has been shed on coding hernia repairs.
 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.