Procedure Code 49560

Repair initial incisional or ventral hernia; reducible 49560

Incarcerated or strangulated 49561  

Implantation of mesh or other prosthesis for open incisional or ventral hernia repair, or closure of debridement (use with 11004–11006, 49560–49566) +49568

Question: We’re having discussions in our surgical practice on a couple of issues related to complex hernia repair. 

1) My surgeon thinks he should be able to bill separately for placement of a xenograft during complex incisional hernia repair using dermal graft codes 15330- 15331. I think the skin graft codes are not appropriate for hernias. Who’s right?

2) When the surgeon does a component separation during the hernia repair, is it appropriate to report 15734?

Answer: To address your first question, both CPT and the American College of Surgeons (ACS) are pretty clear that it would not be appropriate to report an additional graft code when the surgeon places a xenograft mesh as part of an incisional hernia repair.

Here’s what CPT states: “With the exception of the incisional or ventral hernia repairs (codes 49560- 49566), the use of mesh or other prostheses is not separately reported. Therefore, if the ‘open hernia repair’ is for an incisional or a ventral hernia repair, then it would be appropriate to separately report code 49568, Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for the incisional or ventral hernia repair).

From a CPT coding perspective, xenograft mesh is a type of mesh prosthesis appropriately reported with code 49568” (CPT Assistant, June 2008). ACS also warns you away from reporting the 15000 series codes for graft placement during hernia repair.

“All codes in the 15000 series were specifically created for burn wounds, and fall within the skin substitute/ integumentary section of the CPT Codebook,” ACS states in the November 2009 Bulletin of the American College of Surgeons.

“These codes are not intended to be used for abdominal wall fascial repair. More specifically, 15330, Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children, and 15430, Acellular xenograft implant first 10 sq cm or 1% body area of infants or children, are included in this skin substitute section and do not apply to reconstruction of the abdominal wall hernia.”

Coding a flap for component separation

CPT does not address whether it would be appropriate to separately report component separation during complex hernia repair, but ACS states that this would be appropriate. “Some general surgeons now perform component separation of the abdominal wall, where the oblique or transversalis muscles are incised lateral to the hernia and the rectus muscles are mobilized toward the midline, to facilitate wound closure,” the society states.

“For this operation, the use of code 15734, muscle, myocutaneous, or fasciocutaneous flap, trunk, would be appropriate.” ACS further advises its members to apply modifier 50 (bilateral procedure) to 15734 if performed on two sides of the body, and modifier 51 (multiple procedure) if performed through the same incision as the hernia repair. You’ll need to check payer policies to see how they handle these procedures. Two things to note:

• Medicare policy does not allow additional payment for 15734-50 – you’ll only receive payment for one unit of the code, even with the modifier.

• Code 15734 pays $1,315 (all fees par, not adjusted for locality), which is more than any of the incisional hernia repair codes, 49560-49568 (e.g., 49566 [repair recurrent incisional or ventral hernia; incarcerated or strangulated] pays $906.70).

Medicare policy directs you to append the 51 modifier to lesser-valued codes so the multi-procedure payment reduction will be applied to them. But if the primary reason for the surgery is the complex hernia and the flap procedure is supplemental, practices will need to decide whether that is truly appropriate.

Digestive System

CPT Codes 40000-49999

Correspondence Language Policy/Example Number 2.40000 – 
HCPCS/CPT procedure code definition

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

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)

Coding Guidelines

“The work associated with returning a patient to the appropriate post-procedure state is included in the post-procedure work.”

“Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure.

Additionally the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room.

Thus, treatment of a complication of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in the operating room during the procedure or (2) if it occurs postoperatively and does not require return to the operating room.

For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.”

“If a definitive surgical procedure requires access through diseased tissue (e.g., necrotic skin, abscess, hematoma, seroma), a separate service for this access (e.g., debridement, incision and drainage) is not separately reportable. For example, debridement of skin to repair a fracture is not separately reportable.”

“If removal, destruction, or other form of elimination of a lesion requires coincidental elimination of other pathology, only the primary procedure may be reported. For example, if an area of pilonidal disease contains an abscess, incision and drainage of the abscess during the procedure to excise the area of pilonidal disease is not separately reportable.”

“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.”

“If an endoscopic procedure is performed at the same patient encounter as a non-endoscopic procedure to ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic procedure is not separately reportable with the non-endoscopic procedure.”

“By contrast, incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy) are not separately reportable with an addon code. Similarly, complications inherent in an invasive procedure occurring during the procedure are not separately reportable.

For example, control of bleeding during an invasive procedure is considered part of the procedure and is not separately reportable.”

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