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Coding Corner: 3 Tips to Untangling Hernia Repair Coding

Learn expert tricks to match diagnoses with procedures

A physician documents a preoperative diagnosis as "epigastric hernia," a postoperative diagnosis of "epigastric hernia," and then calls the procedure "repair of a ventral hernia." Here's how you can turn this coding nightmare into a reimbursement dream come true.

Translate Clinical to Code
Many surgeons will submit hernia repair documentation that looks like this:
Preoperative diagnosis:  epigastric hernia
Postoperative diagnosis:  epigastric hernia
Procedure: repair of ventral hernia with marlex mesh.
Ideally, this operative report would send up a red flag to both you and your physician. But when you're fuming that the diagnostic part says the hernia is "epigastric" and the procedural part insists it is "ventral" - because those conditions call for different codes - the physician is relying on clinical definitions and isn't necessarily aware of the coding conundrum she's caused. In the operating room, "ventral" can describe any hernia of the abdominal wall (other than an inguinal or femoral hernia), so the doctor's documentation, based on this description, is correct.
According to the clinical definition, you could use ventral hernia repair codes (49560-49566) for the procedure in this operative report. But the discrepancy between these codes and the pre- and postoperative diagnoses will inevitably raise eyebrows with intermediaries. Since the term "ventral," in the clinical sense, can include the epigastrium, but the term "epigastric" refers to a more specific area, you should report a repair code for an epigastric hernia. Choose the more appropriate of these two codes: 49570 (Repair epigastric hernia; reducible) and 49572 (... incarcerated or strangulated).
"It would be very easy to code all abdominal hernias other than inguinal or femoral with ventral hernia codes based on the clinical definition, but the codes need to be based solely on the documentation in the operative report," says Kathleen Mueller, RN, CPC, CCS-P, a registered nurse and reimbursement and coding specialist in Lenzburg, Ill.
Report Mesh Separately for 2 Hernia Types
Coding the physician's insertion of marlex mesh from a conflicting operative report can pose an additional problem, because certain hernia diagnoses allow you to report the insertion separately from the repair, and others don't.
For example, code +49568 (Implantation of mesh or other prosthesis for incisional or ventral hernia repair) represents an add-on service that you can only report with ventral or incisional hernia procedures. But if a surgeon repairs an epigastric or umbilical hernia, you can't charge separately for mesh implantation because intermediaries consider the mesh an aid to the repair.
Similarly, Mueller says, "If the operative report states, 'Repair of epigastric hernia with marlex mesh,' you cannot code the procedure as repair of a ventral hernia because [...]

- Published on 2003-11-06