Procedure code and Description
49560 – Repair initial incisional or ventral hernia; reducible
49561 – Repair initial incisional or ventral hernia incarcerated or strangulated
2016 Coding and Reimbursement Guide for Ventral/Incisional Hernia and Complex Abdominal Wall Repair
The information provided herein reflects Cook Medical’s understanding of the procedure(s) and/or devices(s) from sources that may include, but are not limited to, the CPT® coding system; Medicare payment systems; commercially available coding guides; professional societies; and research conducted by independent coding and reimbursement consultants. This information should not be construed as authoritative. The entity billing Medicare and/or third party payers is solely responsible for the accuracy of the codes assigned to the services and items in the medical record. Cook Medical does not, and should not, have access to medical records, and
therefore cannot recommend codes for specific cases. We encourage you, when making coding decisions, to seek input from the AMA, relevant medical societies, CMS, your local Medicare Administrative Contractor and other health plans to which you may submit claims. Cook Medical does not promote the off-label use of its devices.
Introduction
This guide was developed to assist with Medicare reporting and reimbursement when using Biodesign® grafts during ventral/ incisional hernia and complex abdominal wall repair.
Coverage
Medicare carriers may issue local coverage decisions (LCDs) listing criteria that must be met prior to coverage. Physicians are urged to review these policies (http://www.cms.hhs.gov/mcd/search.asp) and contact their carrier’s medical director (http://www.cms.hhs.gov/apps/contacts/) or commercial insurers to determine if a procedure is covered.
Coding
Using Biodesign during ventral or incisional hernia repair typically involves coding for the repair and the appropriate C-code (when care is provided to Medicare patients in the hospital outpatient setting) to describe the device.
Ventral or incisional hernia repair is typically reported by one of the following Current Procedural Terminology (CPT®) codes. It is the physician’s responsibility to choose a CPT code that accurately describes the procedure performed.
Abdominal Procedures
1. During an open abdominal procedure, exploration of the surgical field is routinely performed to identify anatomic structures and disease. An exploratory laparotomy (CPT code 49000) is not separately reportable with an open abdominal procedure.
2. Hepatectomy procedures (e.g., CPT codes 47120-47130, 47133-47142) include removal of the gallbladder, based on anatomic considerations and standards of practice. A
cholecystectomy CPT code is not separately reportable with a hepatectomy CPT code.
3. A medically necessary appendectomy may be reported separately. However, an incidental appendectomy of a normal appendix during another abdominal procedure is not separately reportable.
4. 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 shall not be reported separately.
5. If a recurrent hernia requires repair, a recurrent hernia repair code may be reported. A code for incisional hernia repair shall not be reported in addition to the recurrent hernia repair code unless a medically necessary incisional hernia repair is performed at a different site. In the latter case, modifier 59 or XS should be used.
6. CPT code 49568 is an AOC describing implantation of mesh or other prosthesis for incisional or ventral hernia repair. This code may be reported with incisional or ventral hernia repair CPT codes 49560-49566. Although mesh or other prosthesis may be implanted with other types of hernia repairs, CPT code 49568 shall not be reported with these other hernia repair codes. If a provider performs an incisional or ventral hernia repair with mesh/prosthesis implantation as well as
another type of hernia repair at the same patient encounter, CPT code 49568 may be reported with modifier 59 or XS to bypass edits bundling CPT code 49568 into all hernia repair codes other than the incisional or ventral hernia repair codes.
Hernia Type Ventral Hernia
Types of Hernia Type
• Strangulated ventral hernia the intestinal tissue is firmly caught within the opening of the abdominal wall and cannot be pushed back. Blood flow is
cut off requiring surgery immediately.
Description
Bulge of tissues through a weakness within the abdominal wall muscles.
Diagnosis
Physical exam, abdominal ultrasound, abdominal CT Scan, abdominal MRI Scan.
Cause & Symptoms
Common causes: pregnancy, obesity, history of previous hernias, previous surgeries, family history, frequent lifting of heavy objects, or injuries to bowel.
Codes
49560, 49561, 49565, 49566, 49568, 49652, 49653, 49654, 49655, 49656, 49657.
Complications Infected mesh
Any downstream episode with CPT 11008 OR, in the synthetic mesh study arm, any downstream episode with ICD9 diagnosis codes 996.60 or 996.69 or a combination of diagnosis and procedure codes*; in the xenograft study arm, any downstream episode with ICD9 diagnosis codes 996.60 or 996.69 or a combination of diagnosis and procedure codes* if the episode occurred within 90 days following the index event (otherwise, the classification changes to infection); in the primary repair study arm, any downstream episode with ICD9 diagnosis codes 996.60 or 996.69 or a combination of diagnosis and procedure codes* occurring subsequent to a post-index implantation of mesh (otherwise, the classification changes to infection).
*The qualifying combination of diagnosis and procedures is an episode that includes a hernia procedure code (CPT code 49560, 49561, 49565, 49566, 49652, 49653, 49654, 49655, 49656, 49657, 49659, S2075, S2077, 11005, 11010, 11011, 11040, 11042, 11043, 44900, 49020, 49021, 49040, 49041, 49060, or 49061;
The Ventral Hernia Working Group (VHWG) developed a grading system to categorize patients based on risk of surgical site occurrences, with recommendations to guide
surgeons regarding the optimal type of mesh to use.3 The system uses patient and wound characteristics to define four grades with progressively increasing risk. Grade 3 includes potentially contaminated patients with a previous wound infection, stoma, or other procedure involving violation of the gastrointestinal tract performed concurrent with the ventral hernia repair, and grade 4 includes patients with infected mesh or septic dehiscence. In grade 3 and 4 patients, the VHWG concludes that synthetic mesh is generally not recommended and biologic mesh should be considered.
In this study, we retrospectively evaluated the health care resource utilization and costs associated with repair of grade 3 and 4 ventral hernias using primary hernia repair alone, repair using synthetic mesh, and repair using a xenograft. Health care resources included length of stay and return hospital visits for recurrences and complications. Hospital costs were estimated for initial repairs and postoperative complications/reoperations.
Materials and methods
We used 2008–2009 insurance claims from US private and Medicare plans from Truven Health Analytics MarketScan® research databases to identify all patients who had an
inpatient grade 3 or 4 ventral hernia repair between January 1 and June 30, 2008, which was designated as the “index event”. Procedures were defined by Current Procedural Terminology (CPT®) codes 49560, 49561, 49565, or 49566 (repair initial or recurrent hernia, either incarcerated or strangulated), 49652–49657 (laparoscopy, repair, ventral/ incisional hernia, either incarcerated/strangulated) or 49659 (unlisted laparoscopic hernia repair). Patients were required to have a minimum of 12 months of continuous insurance coverage following the index event, except for death (as identified by inpatient discharge status).
Ventral hernias were grouped by grade using diagnosis and procedure codes to approximate the criteria specified by the VHWG (Table 1).3 For grade 3 (potentially contaminated), relevant codes occurring in services up to six months prior to the index date were used to identify previous wound infection (including previous septicemia or dehiscence); procedure codes at index date ± 2 days identified concurrent violation of the gastrointestinal tract or stoma creation. For grade 4 (infected), infected mesh was identified if mesh was removed in conjunction with the hernia repair being graded, if debridement was performed or an abscess was drained 0–2 days prior to the index date, or if confirmed by a combination of diagnosis and procedure codes during the hospital stay. Due to limitations of the data, septic dehiscence was defined as the presence of code(s) confirming either septicemia or dehiscence at index ± 2 days. To avoid confusion in attribution of complications, patients were excluded for bariatric surgery during the index event or post-transplant status at index. Codes defining each condition are listed in the online appendix.
Patients meeting the selection criteria were classified by study arm based on CPT or Healthcare Common Procedure Coding System (HCPCS) codes: synthetic mesh was defined by HCPCS C1781 or CPT 49568 (hernia repair with mesh add-on code) in a grade 3 hernia. Xenograft was defined by CPT 15430 or 15431 (acellular xenograft implant) or HCPCS J7347 (nonmetabolic active tissue, nonhuman). Further, any grade 4 hernia repair described as CPT 49568 was assigned to the xenograft arm. This is based on coding practices in 2008 before more specific HCPCS codes were introduced, and because clinical guidelines recommend against using synthetic mesh in an infected hernia.3 Index events involving none of the aforementioned codes were assumed to involve primary repair.
Each patient’s insurance claims for an 18-month postindex (study) period were reviewed to identify servicesrelated to the hernia repair. Complications and hernia recurrences were identified by diagnosis code and/or CPT or ICD9-CM procedure code (see online appendix) and grouped into categories for reporting purposes. A complication was included if it occurred during a defined post-procedure validity period (Table 2) following the index event or a subsequent hernia repair, and excluded if analysis of claims for intervening services revealed a potential alternative cause for the complication
Recent Comments