Monday, October 24, 2016

CPT code 49505, 49560, 49585

procedure code and description

49505 -  Repair initial inguinal hernia > 5 yrs. or over, reducible, under 5 years - average fee payment - $590  - $600

49560 Repair initial incisional or ventral hernia; reducible $946

49561 Repair initial incisional or ventral hernia; incarcerated or strangulated $1,292

49585 Repair umbilical hernia, age 5 or older; reducible

49587 Repair umbilical hernia, age 5 or older; incarcerated or strangulated


Primary hernias

General surgeons usually repair initial hernias, and it is unusual for plastic surgeons to be involved in these primary procedures except in unusual circumstances.

Hernias are either reducible or incarcerated, and separate codes are used to report these situations. If a primary hernia is reducible and it is repaired, code 49560 is used. If the primary hernia is incarcerated, the repair is reported with code 49561. The herniorrhaphy codes are global and include isolation and dissection of the hernia sac, reduction of intraperitoneal contents, fascial repair and soft tissue closure.

If a synthetic mesh is used to bridge or reinforce the fascial tissues, then the add-on code, 49568, is reported in addition to the code for the hernia repair. As with all add-on codes, 49568 is never reported alone and does not take the multiple procedure, "-51," modifier. Thus, the repair of a primary reducible incisional hernia that requires the use of a Marlex® mesh is coded:

49560 Herniorrhaphy, primary, reducible
49568 Implantation of Marlex mesh


Recurrent hernias

Procedures for recurrent hernias are often more complex and occasionally require the involvement of a plastic surgeon, as tissues may be attenuated or absent.

If the recurrent hernia is reducible, the herniorrhaphy is reported with code 49565; if the recurrent hernia is incarcerated, code 49566 is used. Use of synthetic mesh is reported with add-on code 49568 in addition to the herniorrhaphy code. If insufficient fascial tissue is available for closure, incisions may be made in the posterior rectus sheath to allow for advancement of tissues medially. No specific code exists for this maneuver, but this does fall into the realm of complex
repair. This is an additional surgical procedure performed prior to the layered closure (a defect "requiring more than layered closure"), so it is considered a complex repair.

Consider the repair of a recurrent, incarcerated hernia. The sac is dissected and the abdominal contents are reduced. Bilateral longitudinal incisions (each 20 cm. long) are made in the posterior rectus sheaths to facilitate fascial advancement prior to fascial and soft tissue repair. This procedure is coded:

43566 Herniorrhaphy, recurrent, incarcerated


If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 49652-49657) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately.



CPT code 49568 is an add-on code describing implantation of mesh or other prosthesis for incisional or ventral hernia repair. This code may be reported with incisional or ventral hernia repair CPT codes 49560-49566. Although mesh or other prosthesis may be implanted with other types of hernia repairs, CPT code 49568 should not be reported with these other hernia repair codes. If a provider performs an incisional or  ventral hernia repair with mesh/prosthesis implantation as well as another type of hernia repair at the same patient encounter, CPT code 49568 may be reported with modifier 59 to bypass edits bundling CPT code 49568 into all hernia repair codes other than the incisional or ventral hernia repair codes.

Anesthesia service included in surgical procedure

For example, if an ilioinguinal or iliohypogastric nerve block (procedure  code 64425) is performed for anesthesia by the physician performing an inguinal hernia repair (procedure  code 49505), the nerve block is included in the surgical procedure and is not reported separately. Therefore, procedure  code 64425 is bundled into procedure  code 49505.



For example, the code descriptor for procedure  code 45805 is “Closure of rectovesical fistula;  with colostomy” and the code descriptor for procedure  code 45800 is “Closure of rectovesical fistula;”. Therefore, based upon the code descriptors the procedure described by procedure  code 45800 is a component of the procedure described by procedure  code 45805, and procedure  code 45800 is bundled into procedure  code 45805.



For example, the procedure  Manual instruction above procedure  code 49491 states: “With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prostheses is not separately reported.” Therefore, procedure  code 49568 (mesh implantation) should not be reported separately with procedure  code 49505 (inguinal hernia repair).


Correspondence Language Policy/Example Number 3.40000 - CPT Manual or CMS manual coding instruction

For example, the CPT Manual instruction above CPT code 49491 states: “With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prostheses is not separately reported.” Therefore, CPT code 49568 (mesh implantation) should not be reported separately with CPT code 49505 (inguinal hernia repair).

Effective for dates of service on and after November 1, 2004, authorization is no longer required for the following Surgical and Ambulatory procedure codes with type of service 2/8/F: procedure code 43234, upper GI endoscopy, exam; procedure code 45379, Colonoscopy w/fb removal; and procedure code 49505, Prp i/ hern init reduc>5 yr. For more information, visit the TMHP website at www.tmhp.com or call the TMHP Contact Center at 1-800-925-9126


Correspondence Language Policy/Example Number 4.40000 - Mutually exclusiveprocedures

For example, CPT codes 43100 and 43101 describe different approaches to the excision of an esophageal lesion. CPT code 43100 describes a cervical approach, and CPT code 43101 describes a thoracic or abdominal approach. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.


New Edit #805 49585 bundles with 43880

Rationale: The performance of an abdominal procedure includes the reimbursement for hernia repair. The CMS National Correct Coding Manual states: “If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., procedure  codes 49560-49566, 49652-49657) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately.” Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed.

Rationale

Anthem Central Region bundles procedure  49585 as incidental to procedure  43880. The performance of an abdominal procedure includes the reimbursement for hernia repair. The CMS National Correct Coding Manual states:

“If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., procedure  codes 49560-49566, 49652-49657) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately.” Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed.


INGUINAL HERNIA 49492

Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or strangulated $884.93 0154 Hernia/Hydrocele Procedures $2,675.43 Not reimbursed in ASC by Medicare 49495

Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time o  surgery, with or without hydrocelectomy; reducible $383.29 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02 49496

Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated $563.49 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02

49500 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible $423.69 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02 49501

Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated $625.71 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02

49505 Repair initial inguinal hernia, age 5 years or older; reducible $536.68 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02

49507 Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated $603.90 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02

49520 Repair recurrent inguinal hernia, any age; reducible $652.17 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02

49521 Repair recurrent inguinal hernia, any age; incarcerated or trangulated $739.05 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02 49525 Repair inguinal hernia, sliding, any age $590.67 0154 Hernia/Hydrocele Procedures $2,675.43 $1,466.02



Incisional (Ventral) Hernia CPT Code Procedure National Average Payment Rate

49560 Repair initial incisional or ventral hernia; reducible $946
49561 Repair initial incisional or ventral hernia; incarcerated or strangulated $1,292
49565 Repair recurrent incisional or ventral hernia; reducible $946
49566 Repair recurrent incisional or ventral hernia; incarcerated or strangulated $1,292
49568** Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing tissue infection.  (List separately in addition to code for the incisional or ventral hernia repair.) $1,124
49650 Laparoscopy, surgical; repair initial inguinal hernia $1,242
49651 Laparoscopy, surgical; repair recurrent inguinal hernia $1,420
49652*** Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible $1,529
49653*** Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated $1,529
49654*** Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible $1,529
49655*** Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated $1,529
49656*** Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible $1,529
49657*** Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated $1,529


Covered ICD Diagnostic Codes

551.1 Umbilical hernia with gangrene
551.20 Unspecified ventral hernia with gangrene
551.21 Incisional ventral hernia, with gangrene
551.29 Other ventral hernia with gangrene
551.3 Diaphragmatic hernia with gangrene
551.8 Hernia of other specified sites, with gangrene
552.1 Umbilical hernia with obstruction
552.20 Unspecified ventral hernia with obstruction
552.21 Incisional hernia with obstruction
552.29 Other ventral hernia with obstruction
552.3 Diaphragmatic hernia with obstruction
552.8 Hernia of other specified site, with obstruction Umbilical hernia without mention of obstruction or gangrene
553.1 Unspecified ventral hernia without mention of obstruction or gangrene
553.20 Incisional hernia without mention of obstruction or gangrene
553.21 Other ventral hernia without mention of obstruction or gangrene
553.3  Hernia of other specified sites of abdominal cavity without mention of obstruction or gangrene
553.8 Disruption of cesarean wound, unspecified as to episode of care
674.10 Disruption of cesarean wound, with delivery, with mention of postpartum complication
674.12 Disruption of cesarean wound, postpartum condition or complication
674.14 Other complication of obstetrical surgical wounds, unspecified as to episode of care
674.30 Other complication of obstetrical surgical wounds, with delivery, with mention of postpartum complication
674.32 Other complications of obstetrical surgical wounds, postpartum condition or complication 674.34
756.79 Other congenital anomalies of abdominal wall Diaphragm injury without mention of open wound into cavity 862.0
998.31 Disruption of internal operation (surgical) wound
998.32 Disruption of external operation (surgical) wound

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