Differentiate hernia repairs and surgical approaches for improved medical coding.
A hernia occurs when an internal part of the body pushes or squeezes through a weak spot in a surrounding muscle or connective tissue (fascia). Although most hernias are harmless and pain-free, some may be painful and dangerous. Surgery is the only cure for a hernia.
There are two approaches for surgical hernia repair: open and laparoscopic. In both approaches, a synthetic or prosthetic mesh may be used to strengthen the repair.
Hernia repair codes are categorized primarily by the type of hernia such as:
- Inguinal (inner groin)
- Femoral (outer groin)
- Incisional (resulting from incision)
- Umbilical (belly button)
- Hiatal (upper stomach)
Some types of hernias are further categorized as “initial” or “recurrent,” based on whether the hernia has required previous repair. Additional variables include patient age and clinical presentation (reducible, incarcerated, or strangulated).
The classifications in Chart A describe the different types of hernias and code ranges by approach.
Hernia repair codes 49491-49651 are unilateral procedures; if performed bilaterally, append modifier 50 Bilateral procedure to the appropriate code(s), rather than report two units with modifiers RT Right side and LT Left side appended. If hernia repair is unilateral, use modifier RT or LT to indicate the site.
Hernia mesh is a surgical implant that provides additional support to the damaged tissue. The main reason surgeons use hernia mesh is to reduce the risk of recurrence. Hernia mesh is used in approximately 90 percent of hernia surgeries.
Add-on code 49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) can be used only with incisional or ventral hernia repairs (49560-49566).
If implantation of mesh is performed with other hernia repairs (inguinal, umbilical, femoral, laparoscopic), do not report +49568 because mesh placement is included.
Mesh is always a part of laparoscopic repair: Do not report +49568 with laparoscopic ventral/incisional hernia repair.
If recurrent hernia repair is done with removal of implanted mesh from a previous surgery, removal of mesh is included in the recurrent hernial repair and should not be coded separately. If additional time is taken to dissect the old mesh, proper reimbursement can be gained by adding modifier 22 Increased procedural service to the recurrent hernia repair code.
Do not use add-on code 11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) for removal of mesh during hernia repair. This code is for use only with 10180 Incision and drainage, complex, postoperative wound infection and 11004-11006:
11004 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum
11005 abdominal wall, with or without fascial closure
11006 external genitalia, perineum and abdominal wall, with or without fascial closure
If implanted mesh from previous surgery is removed without recurrent hernial repair, report the mesh removal separately. There is no separate code of implanted mesh removal (mesh is not considered to be a foreign body because it was implanted deliberately); report unlisted procedure code 49999 Unlisted procedure, abdomen, peritoneum and omentum.
Tip: It’s best practice to submit unlisted code claims with a full operative report to avoid denials.
Four Takeaway Tips
1. Report implantation of mesh (49568) only with open incisional/ventral hernia repair.
2. Do not bill for mesh implantation billed if laparoscopic hernia repair was performed. Mesh is always placed during laparoscopic hernia repairs and included in the repair code.
3. If a hernia repair is performed during another open abdominal procedure, report the hernia repair only if it is medically necessary and performed at a different incision site. Do not report incidental hernia repair performed during other abdominal procedures (e.g., cholecystectomy) that is not medically necessary.
4. Hernia repairs have a 90-day global period.
Shruthi Sargur Ravindranath, CPC, has 12 years of experience in medical coding. She is associated with Exdion Solutions, Pvt, Ltd, as senior team lead. Ravindranath is a subject matter expert in multiple specialties including evaluation and management, neurosurgery, gastrointestinal, orthopedics, obstetrics/gynecology, general surgery, and internal medicine. She is a member of the Bangalore, India, local chapter.