CPT Code 49585 Repair umbilical hernia

49585 Repair umbilical hernia, age 5 years or older; reducible

Hospital Outpatient Department

APC 5341

APC Description

Peritoneal and Abdominal Procedures (CPT codes: 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49600)

Ambulatory Surgery Center

CPT CODE 

49495, 49496, 495ØØ, 495Ø1, 495Ø5, 495Ø7, 4952Ø, 49521, 49525, 4954Ø, 4955Ø, 49553, 49555, 49557, 4956Ø, 49561, 49565, 49566, 4957Ø, 49572, 4958Ø, 49582, 49585, 49587, 4959Ø, , 496ØØ

Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit

Subject: Repair of reducible umbilical hernia with closure of gastrocolic fistula

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. 

Description CODE : 49585

Rationale

Anthem Central Region bundles CPT 49585 as incidental to CPT 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., 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.”

Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed. 

CPT Codes

15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. abdominoplasty) (includes umbilical transposition and fascial placation)

49560 Repair initial incisional or ventral hernia; reducible

49561 Repair initial incisional or ventral hernia; incarcerated or strangulated

49585 Repair umbilical hernia, age 5 or older; reducible

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


INDEPENDENT BILLING REVIEW FINAL DETERMINATION 

Disputed Codes: Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010


ANALYSIS AND FINDING

Based on review of the case file the following is noted:

 ISSUE IN DISPUTE: Provider seeking contractual reimbursement for Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010 for date of service 04/30/2015.

 The Claims Administrator reimbursement rational: “Official Medical Fee Schedule,” and “contract indicated.”

Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010

BCBSIL Significant Edits - 49585

BCBSIL utilizes an automated code auditing system that is designed to review reported codes to ensure that the correct procedure codes are identified for reimbursement. Claims are audited to review for potential incorrect billing. The following codes represent those procedures that are reported in high volume and that are not separately payable when billed in conjunction with other procedures.

This service is incidental to primary procedure code. Payment is included in allowance for primary service. 

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