What is Hernia?
Hernia is when an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue called fascia. There are several types of hernia including inguinal (inner groin), incisional (resulting from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper stomach). [1]
How is it Billed?
There are different Current Procedural Terminology Codes (CPT) based on the type of hernia and the surgical approach. However, 2023 brought many change to this section of codes to address reporting of “hybrid” abdominal hernia repair procedures where the procedure is performed via open approach and laparoscopically or with the use of a robot. The following codes were deleted from CPT 2023:
- 49560-Repair initial incisional or ventral hernia; reducible
- 49561-Repair initial incisional or ventral hernia; incarcerated or strangulated
- 49565-Repair recurrent incisional or ventral hernia; reducible
- 49566-Repair recurrent incisional or ventral hernia; incarcerated or strangulated
- 49570-Repair epigastric hernia (e.g., preperitoneal fat); reducible (separate procedure)
- 49572-Repair epigastric hernia (e.g., preperitoneal fat); incarcerated or strangulated
- 49580-Repair umbilical hernia, younger than age 5 years; reducible
- 49582-Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated
- 49585-Repair umbilical hernia, age 5 years or older; reducible
- 49590-Repair spigelian hernia
The new codes combine some of the various types of hernia into one set of codes creating 15[2] new CPT codes. The codes bundle epigastric, incisional, ventral, umbilical, and spigelian hernia repair, whether open or laparoscopic, into one category, anterior abdominal hernia. In 2023, you report one code based on initial or recurrent, reducible or incarcerated/strangulated, and repair size, as follows:
- 49591-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible
- 49592-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, incarcerated or strangulated
- 49593-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible
- 49594-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated
- 49595-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible
- 49596-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, incarcerated or strangulated
- 49613-Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible
- 49614-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, incarcerated or strangulated
- 49615-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible
- 49616-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated
- 49617-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible
- 49618-Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, incarcerated or strangulated
- 49621-Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; reducible
- 49622-Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; incarcerated or strangulated
- +49623-Removal of total or near total non-infected mesh or other prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair, any approach (i.e., open, laparoscopic, robotic) (List separately in addition to code for primary procedure)
Providers will also have a choice of new codes for repair of parastomal hernias reducible (49621) or incarcerated/strangulated (49622).
In 2023 as shown above, providers will also have a choice of new codes for repair of parastomal hernias reducible (49621) or incarcerated/strangulated (49622) and a new add-on code (+49623) for removal of mesh or other prosthesis.
What to look for?
- Upcoding the size of the repair
- Coding initial when performing recurrent
- Medically unnecessary surgeries (check the appropriate medical policies and guidelines)
[1] https://www.webmd.com/digestive-disorders/understanding-hernia-basics