Coding and Practice Management

Over the years, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) Specialty Society RVS Update Committee (RUC) have identified Current Procedural Terminology* (CPT) codes that are performed less than 50% of the time in the inpatient setting and that include inpatient hospital evaluation and management (E/M) services codes in the CMS physician time and visit database. The intent of this site-of-service anomaly screen was to determine if the work relative value units (wRVUs) for procedures were potentially misvalued because the codes included inpatient E/M visit codes even though the procedures typically were performed in an outpatient setting. The concern was that the payment should reflect the typical patient, and if the typical patient has a facility status of outpatient, then the wRVUs and time/visit database may not include inpatient E/M services codes. The most recent review of codes using the site-of-service anomaly screen identified codes for reporting abdominal hernia repair. The ACS and other stakeholder societies took the following steps to avert potential underpayment for hernia repair procedures resulting from the CMS “typical patient” payment policy.

Site-of-Service Anomaly Screen

The first RUC and CMS review of codes identified by the site-of-service anomaly screen resulted in a 7% to 12% decrease in wRVUs for seven open and laparoscopic hernia repair codes for 2012. More recently, code 49565, Repair recurrent incisional or ventral hernia; reducible, was identified by the RUC as a service performed less than 50% of the time in the inpatient setting that included inpatient hospital E/M service codes and had Medicare utilization of more than 5,000 paid claims. Although only code 49565 was identified under the screen’s criteria, both the RUC and CMS currently require review of all family codes when one or more codes are identified as potentially misvalued. This means that all open and laparoscopic hernia codes would need to be reviewed for physician work.

The ACS, Society of American Gastrointestinal and Endoscopic Surgeons, and American Society of Colon and Rectal Surgeons determined that payment for the typical hernia repair patient will result in all codes being under-reimbursed. Said another way, if 60% of patients were discharged the same day or the next day as outpatient, then all claims would be reimbursed as if all patients were outpatient because that was typical. Instead of submitting to a physician work review of code 49565 and related family codes, which likely would result in significant wRVU decreases based on the typical patient policy, the three societies recommended referring the codes to CPT to update the codes. This better describes hernia repair procedures as performed in current practice, taking into consideration the use of mesh, hybrid procedures, and length of stay. 

Mesh Implantation or Excision

Literature supports implantation of mesh as typical for both open and laparoscopic/robotic hernia repair procedures, along with other abdominal procedures. Coders frequently ask how to report the significant work for mesh removal when performing an initial or recurrent abdominal hernia repair, because mesh implantation is not included in the current work value for these procedures. Mesh implantation and removal with stomal hernia repair also is a common coding question. Consequently, any changes to hernia repair coding required consideration of the use and removal of mesh.

Hybrid Procedures

The stakeholder societies and the AMA recently have received coding questions about correct reporting for “hybrid” abdominal hernia repair procedures where parts of the procedure are performed via an open approach and parts of the procedure use laparoscopy and/or a robot. These are not laparoscopic procedures converted to open procedures, but instead procedures that may start via an open approach and finish using a laparoscopic/robotic approach under pneumoperitoneum. A column in the June 2019 issue of the Bulletin clarified questions regarding correct coding for hybrid procedures. This was in response to changes to the International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10-PCS) codes that classify procedures for facility reporting that do not correspond to CPT coding (closed, percutaneous, open, laparoscopic).^†

Consequently, any changes to hernia repair coding required consideration of the approach, including a hybrid approach.

Size, Number, and Type of Hernia Defect(s)

It is important to differentiate the total size of a hernia defect, as this affects the total physician work. For example, current coding for repair of a “Swiss cheese” incisional hernia that has a large total defect is coded the same as a single small incisional hernia. In addition, the repair of anterior abdominal hernias (i.e., epigastric, incisional, ventral, umbilical, spigelian) and parastomal hernias is similar.

Global Period Consideration

A global period of 0 days was recommended and accepted for new primary anterior abdominal hernia repair codes, a change that will allow correct reporting of hospital and office E/M visit codes in the postoperative period. For example, if the patient stays overnight and is discharged the next day, CPT code 99238 or 99239 can be reported for discharge management on the day after the procedure. On the other hand, if the patient is admitted and stays 5 days in the hospital, the surgeon can report an inpatient E/M visit code for each hospital day that a visit occurs. If this family of codes retained a 90-day global assignment, only the reduced work for outpatient discharge management would be included in the 90-day global payment since the typical patient for most hernia repairs is an outpatient. In addition, because the codes will have a 0-day global assignment, additional procedures (wound debridement, suture/staple removal) will be separately reportable even if the procedure does not require a return to the operating room (OR).

Summary of 2023 CPT Coding Changes

For 2023, CPT approved significant coding changes, as summarized in this column. The full 2023 CPT code descriptors are presented in Table 1.

• Delete codes 49560–49590, which describe open repair of anterior abdominal hernias
• Delete codes 49652–49657, which describe laparoscopic repair of anterior abdominal hernias
• Delete add-on code 49568, which describes implantation of mesh for open ventral/incisional hernias and defects resulting from necrotizing soft tissue infection 
• Add 12 new codes (49591–49596 and 49613-49618)^‡ to report anterior abdominal hernia repair by any approach (i.e., open laparoscopic, robotic), further by initial or recurrent hernia, further by total defect size, and further by reducible or incarcerated/strangulated
• Add two new codes (49621–49622)^‡ to report parastomal hernia repair by any approach (i.e., open laparoscopic, robotic), further divided by reducible or incarcerated/strangulated
• Add one new add-on code (49623)^‡ for removal of mesh/prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair
• Add one new code (15778)^‡ for implantation of absorbable mesh or other prosthesis for delayed closure of external genitalia, perineum, and/or abdominal wall defect(s) due to soft tissue infection or trauma
• Add two new add-on codes (15853–15854)^‡ for removal of sutures/staples not requiring anesthesia, to be reported separately in addition to an E/M code 

Coding Guidance

Codes 49591–49596 and 49613–49618 describe repair of an anterior abdominal hernia(s) (epigastric, incisional, ventral, umbilical, spigelian) by any approach (open, laparoscopic, robotic). Codes 49591–49596 and 49613–49618 are reported only once, based on the total defect size for one or more anterior abdominal hernia(s). When both reducible and incarcerated/strangulated anterior abdominal hernias are repaired at the same operative session, all hernias are reported as incarcerated/strangulated. For example, one 2 cm reducible initial incisional hernia and one 4 cm incarcerated initial incisional hernias separated by 2 cm would be reported as an initial incarcerated hernia repair with a maximum craniocaudad distance of 8 cm and reported with code 49594. Inguinal, femoral, lumbar, omphalocele, and/or parastomal hernia repair may be separately reported when performed at the same operative session as anterior abdominal hernia repair by appending modifier 59, Distinct Procedural Service, as appropriate.

Codes 49621 and 49622 describe repair of a parastomal hernia (initial or recurrent) by any approach (open, laparoscopic, robotic). Code 49621 is reported for repair of a reducible parastomal hernia and code 49622 is reported for an incarcerated or strangulated parastomal hernia. For parastomal hernia repair, it was determined that size and initial verus recurrent hernia were not key factors for work that required separate additional codes.

Implantation of mesh or other prosthesis, when performed, is included in 49591–49596, 49613–49618, and 49621–49622 and may not be separately reported no matter the approach (open, laparoscopic, robotic). For total or near-total removal of noninfected mesh, report add-on code 49623 in conjunction with 49591–49596, 49613–49618, and 49621–49622. For removal of infected mesh, see codes 11004, 11005, 11006, and 11008.

Measuring Hernia Defect(s)

Codes 49591–49596 and 49613–49618 are reported only once, based on the total defect size for one or more anterior abdominal hernia(s). In addition, the total hernia defect size should be measured before opening the hernia defect(s) because during repair the fascia typically will retract, creating a falsely elevated measurement. Hernia measurements are performed either in the transverse or craniocaudal dimension. The total length of the defect(s) corresponds to the maximum width or height of an oval drawn to encircle the outer perimeter of all repaired defects. If the defects are not contiguous and are separated by greater than or equal to 10 cm of intact fascia, total defect size is the sum of each defect measured individually. Without a total size indicated, coders may be inclined to report the hernia repair code for the smallest defect. Therefore, it will be very important to document the total defect size in the operative report so coders will know which code to select.

Figure 1 depicts measuring a single anterior abdominal hernia defect, such as an umbilical hernia. Figure 2  depicts measuring multiple anterior abdominal hernia defects. For example, Swiss cheese defects would be measured from the superior-most aspect of the upper defect to the inferior-most aspect of the lowest defect. Figure 3 depicts measuring remote abdominal hernia defects separated by 10 cm or more of intact fascia, such as a defect in the lower right quadrant from a prior open appendectomy and a separate hernia in the upper left quadrant from a previous laparoscopic port placement.

Reporting Postoperative Work

Assigning a 0-day global period to the new anterior abdominal family of codes requires the surgeon to separately report all procedures and services performed beginning the day after the operation, including hospital visit E/M codes 99231–99233, discharge management codes 99238–99239, office visit E/M codes 99211–99215 (in-person or via telehealth, as allowed), and any other E/M services code, when appropriate, such as telephone E/M codes 99441–99443, online digital E/M codes 99421–99423, or principal care management codes 99424–99427.

In addition, codes for procedures performed after the day of surgery will be separately reportable even if they do not require a return to the OR—for example, wound debridement or wound repair including resuturing. When sutures/staples are removed during an office visit, new add-on codes 15853–15854 may be reported in addition to the E/M visit code. Codes 15853–15854 are practice-expense-only codes that include clinical staff time, supplies, and equipment related to suture/staple removal.

Although there will be more claims reported in the postoperative period, this increase should not be a burden to surgeons who already will be completing a chart for every patient encounter, whether in the hospital or the office. With respect to additional patient copays for each encounter, this situation is not different than patients being admitted for medical (nonsurgical) issues that include daily copays for the primary physician visits and all consultant visits, along with subsequent postdischarge follow-up office visits. 

Learn More

The ACS collaborates with KarenZupko & Associates (KZA) to offer coding courses that provide the tools necessary to increase revenue and decrease compliance risk. These courses are an opportunity to sharpen your coding skills. You also will be provided online access to the KZA alumni website, where you will find additional resources and frequently asked questions about correct coding. Information about the courses and registration can be accessed at karenzupko.com/general-surgery.

In addition, as part of the College’s ongoing efforts to help Fellows and their practices submit clean claims and receive proper reimbursement, a coding consultation service—the ACS Coding Hotline—has been established for coding and billing questions. ACS Fellows are offered five free consultation units (CUs) per calendar year. One CU is a period of up to 10 minutes of coding services time. Access the ACS Coding Hotline website at prsnetwork.com/acshotline.

*All specific references to CPT codes and descriptions are © 2022 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.

^†Orangio G, Selzer D, Savarise M. Coding and practice management corner: Correct CPT coding of colectomy procedures: Open or laparoscopic? Bull Am Coll Surg. 2019;104(7):46-47.

^‡2023 CPT code numbers will be effective January 1, 2023. For procedures performed in 2022, continue to use 2022 CPT codes for hernia repair. 

Dr. Megan McNally is a surgical oncologist in the St. Luke’s Health System, Kansas City, MO, and assistant clinical professor at the Department of Surgery, University of Missouri-Kansas City School of Medicine. She also is a member of the ACS General Surgery Coding and Reimbursement Committee and ACS advisor to the AMA CPT Editorial Panel.