Continue to Use Unlisted-Procedure Code for Laparoscopic Ventral Hernia Repair

Published: 22nd March 2012
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General surgeons who expected CPT 2002 to include a code for reporting laparoscopic repair (LR) of ventral/incisional hernias, take note: Continue to use unlisted-procedure code 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy) to report this procedure.

Although CPT 2002 includes two codes for LR of inguinal hernias 49650 (Laparoscopy, surgical; repair initial inguinal hernia) and 49651 ( repair recurrent inguinal hernia) it does not include a code for LR of ventral/incisional hernias. These complications commonly develop after a patient has had open abdominal surgery, and they often require surgical repair. Fascia and skin are sutured closed after surgery. When the fascial repair breaks down, an incisional hernia forms. These are typically seen as a bulge (arising through the fascial defect) deep to the visible skin scar.

Traditional/Open Repair

Traditional/open repair involves reopening the original surgical incision, placing sutures and (often but not always) covering the abdominal wall fascial defect with a prosthetic mesh.

Codes for reporting traditional/open repair of ventral/incisional hernias include 49560 (Repair initial incisional or ventral hernia; reducible), 49561 ( incarcerated or strangulated), 49565 (Repair recurrent incisional or ventral hernia; reducible) and 49566 ( incarcerated or strangulated).

Consider the following when coding these traditional/open procedures:

Has a prior repair been performed? If this is the first incisional hernia repair performed at the site, an initial" repair was performed. Subsequent repairs are considered "recurrent" and are typically more difficult than an initial repair. Use 49560 or 49561 for initial repairs and 49565 or 49566 for subsequent ones.

How severe is the hernia? "Reducible" hernias are typically less dangerous and easier to correct. "Incarcerated or strangulated" hernias can be life-threatening. Use 49560 or 49565 for the former and 49561 or 49566 for the latter.

Note: Although a ventral/incisional hernia is the result of a prior incision it may be reported inappropriately as "recurrent" when actually it is the first time this problem is being addressed. If a ventral/incisional hernia is repaired at the same time as a recurrent one at a separate site and is medically necessary report it separately with modifier -59 (Distinct procedural service) appended.

Laparoscopic Repair

LR differs from traditional/open repair in that the mesh is placed from inside the abdomen rather than from outside.

Although LR is more difficult and costly than traditional/open repair many general surgeons opt for this method (especially for large and complex hernias) because 1) the results of traditional/open repair are not always satisfactory 2) LR's risk of complication is lower 3) its hospital stay is shorter and 4) LR has a lower recurrence rate.

Unlisted-procedure code 49659 is used to report LR of ventral/incisional hernias (in the absence of a CPT code for this particular procedure) making it difficult for practices to price and document this procedure. "When you submit a claim with an unlisted code sometimes it's like you're sending it into the Twilight Zone " says Kathleen Mueller RN CPC CCS-P a general surgery coding and reimbursement specialist in Lenzburg Ill. "Unfortunately there's no other choice here."

Pricing. A surgeon who performs LR more frequently than traditional/open repair should negotiate with his or her carrier on a set fee for the service.

Documentation. A description of the repair should be entered in the comment field of the electronic claim form explaining why a laparoscopic approach was taken and indicating the size of the hernia (LR is typically performed on complex hernias bigger than 3 cm). The following should also be noted in the medical record: the patient's history of hernia repair a short description of the surgery whether the hernia being repaired is unilateral or bilateral whether it is reducible or incarcerated/strangulated and how mesh is used.

Note: Although unlisted-procedure codes normally require manual review before they are paid Mueller recommends that they still be billed electronically so claims are filed on time. The documentation still needs to be forwarded to the carrier at some point she adds.

Rely on Unlisted-Procedure Code

Some carriers require that LR be billed using a similar traditional/open repair code with modifier -22 (Unusual procedural services) appended if the procedure was more difficult or with modifier -52 (Reduced services) appended if it was less difficult than its associated traditional/open repair code. If this is the case the policy should be obtained in writing because CPT specifically instructs physicians not to code that way says Susan Callaway CPC CCS-P a coding and reimbursement specialist and educator in North Augusta S.C.

"If you do a scope procedure and there is no scope code CPT says you should use the unlisted code for that body area. You do not use a comparable open code " Callaway says. Following CPT's advice in this matter may help convince the AMA to introduce a new code for the procedure she adds. "You have to use the unlisted code to see how often a procedure is being performed. If the LR is billed as a traditional/open repair with a modifier the procedure cannot be easily recognized for what it is and the need for a code for LR may remain on the back burner."

Related Issues

Mesh placement. Unlike traditional/open repair of ventral/incisional hernias LR always involves placing mesh from inside the abdomen. Mesh placement is inclusive to the repair (i.e. cannot be reported separately) because the repair cannot be performed without it. Another compelling reason for not billing separately for mesh placement Callaway says is that LR is reported using an unlisted-procedure code. "Unlike listed CPT codes which describe a specific procedure unlisted codes are open-ended and all components of such a procedure are automatically considered part of it. In this case that includes the placement of the mesh."

Conversion to traditional/open repair. A laparoscopic procedure may have to be discontinued in favor of a traditional/open procedure for any of several reasons such as dense scarring or adhesions that may limit visibility intestinal or other abdominal tissue trauma bleeding problems or obesity.

Medicare guidelines state that only the appropriate traditional/open repair code (i.e. not the unlisted-procedure code for LR) should be reported in these cases.

In contrast the AMA has not revised its 1994 policy statement that laparoscopic procedures converted to traditional/open may be billed with modifier -52 (Reduced services) appended in addition to the traditional/open procedure Callaway notes.

Most private carriers follow Medicare on this issue but if yours pays separately for the laparoscopic procedure in such cases its policy should be obtained in writing she recommends."

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