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Questions to Consider When Coding Hernia Repairs

When you look at hernia codes one thing becomes quite clear, there is a good bit of diagnostic and demographic information you need to know to get to the correct code.  For example: Repair initial inguinal hernia, age 5 years or older; reducible (49505). The key to properly coding hernia procedures is knowing what questions to ask yourself as you read through the patient’s health record. 

We will start with an easy one: Was the repair open or laparoscopic?  If it’s “laparoscopic” go to code categories 49650-49659 and choose the site and complication. Tada!  Done.  If it’s “open” we have a bit more work to do.

First, check the diagnostic information for the location or type of hernia.  These would be areas such as: inguinal, femoral, umbilical, lumbar, epigastric, or Spigelian.  Refer to the information below for a little more information on each type.

  • Inguinal – occurs in a weak area in the groin muscle allowing underlying tissues to herniate
  • Femoral – occurs when the intestine bulges through the lower abdomen just below the groin crease
  • Lumbar – extremely rare and occurs when a protrusion of either extraperitoneal fat or intraperitoneal contents bulge through either of the lumbar triangles
  • Incisional – occurs months or years after surgery on the abdomen
  • Umbilical – intestine, fat, or fluid herniates through a weak area in the muscle near the belly button
  • Epigastric – occurs between the breast bone and belly button
  • Hiatal – occurs when the stomach bulges up through the diaphragm
  • Spigelian – also known as lateral ventral hernia and is a hernia through the Spigelian fascia

Next, what is the age of the patient? Less than 6 months, between 6 months and 5 years, or 5 years and older.  Note that not all hernia code categories have aged as a component.

Next, what are the manifestations or complications associated with the hernia? Is it reducible, obstructed, incarcerated, strangulated, sliding, or recurrent?  Refer to the information below for more information.

  • Incarcerated – occurs when herniated tissue becomes trapped and cannot easily be moved back into place
  • Strangulated – occurs when the muscle surrounding the hernia clamps down, cutting off the blood supply to the protruding tissue (often small intestine)
  • Reducible – The contents in the hernia are pushed back and the hernia sac is excised
  • Recurrent – Prior repair
  • Sliding (inguinal)- part of the hernial sac wall is formed by an organ such as the colon or bladder

Finally, was the mesh inserted? The use of mesh is included in most CPT codes except for incisional, ventral, or for closure after debridement of infection.  Incisional hernias are also known as ventral hernias because they are caused by an incompletely healed surgical incision. 

Understanding the specific details associated with hernia repair is imperative for proper coding and reporting.  Our coders are provided both clinical and coding education through our LMS (learning management system) to help them understand these nuances and prevent the over-coding or under-coding commonly seen among inexperienced coders.  We have the workforce solutions to assist with all of your HIM coding needs.