Procedure code and Description
49505 – Repair initial inguinal hernia, age 5 years or older; reducible
49507 – Repair initial inguinal hernia, age 5 years or older; incarcerated
49520 – Repair recurrent inguinal hernia, any age; reducible
49521 – Repair recurrent inguinal hernia, any age; incarcerated
49525 – Repair inguinal hernia, sliding, any age
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).
REPAIR HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY
The hernia repair codes in this section are categorized primarily by the type of hernia (inguinal, femoral, incisional, etc.). Some types of hernias are further categorized as “initial” or “recurrent” based on whether or not the hernia has required previous repair(s). Additional variables accounted for by some of the codes include patient age and clinical presentation (reducible vs. incarcerated or strangulated).
With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prosthesis is not separately reported.
(Codes 49491-49651 are unilateral procedures. To report bilateral procedures, report modifier -50 with the appropriate procedure code)
(Do not report modifier -63 in conjunction with 49491, 49492, 49495, 49496, 49600, 49605, 49606, 49610, 49611)
49505 Repair initial inguinal hernia, age 5 years or over; reducible
49505-LT
RATIONALE: In the CPT® Index, look up Hernia Repair/Inguinal/Initial, Child 5 Years or Older. You are referred to 49491, 49495–49500, and 49505 and 49507. Review the codes to choose the appropriate service. 49505 is the correct code. The repair was through an incision (not by laparoscopy) on an initial inguinal hernia on a patient over five years of age and the hernia was not incarcerated or strangulated. According to CPT® guidelines, “With the exception of the incisional hernia repairs (49560–49566), the use of mesh or other prosthesis is not separately reported.” It would be inappropriate to code the mesh in this scenario.
Hernia Type Inguinal Hernia
Types of Hernia
• Incarcerated Hernia- hernia that is trapped in the abdominal wall.
• Strangulated Hernia- An incarcerated hernia that becomes strangulated cutting the blood flow. Symptoms of this include nausea, high fever, sharp pains and swelling
Type Description
Occurs when tissue protrudes through a weak spot in the abdominal muscles/groin area.
Diagnosis
Physical exam, ultrasound, CT Scan or MRI
Cause & Symptoms
Common causes: Increased pressure w/in the abdomen, pregnancy, chronic coughing or sneezing, or strenuous activity. Symptoms can include: Stomach muscle weakness,sharp pain, swelling in scrotum, or bulge in groin.
Measures of Inguinal Hernia Repair Surgeries by Setting
For each hospital and year in our sample, we construct separate counts of inguinal hernia repair surgeries performed in the outpatient setting and in the inpatient setting; both counts are done for discharges where the primary payer was fee-for-service Medicare. We identify outpatient hernia repair surgeries from CPT codes and inpatient surgeries from ICD-9-CM procedure codes. To select the relevant procedure codes, we used the Clinical Classification Software (CCS) developed by the Agency for Healthcare Quality and Research (AHRQ 2012a,b).
The CCS assigns multiple CPT and ICD-9 procedure codes to CCS 85 (inguinal and femoral hernia repair). Of the 19 CPTs codes in CCS 85, we eliminated four procedures pertaining to femoral hernia and six procedures used to treat children. As the clinical studies cited earlier showed comparable patient outcomes following open inguinal hernia repair, we excluded four CPTs used for laparoscopic hernia repair. Payment rate data for one open inguinal hernia repair procedure (CPT 49521) are not available for a large share of hospitals in our sample. Our analysis thus includes four procedures used in the open repair of inguinal hernia (CPTs 49505, 49507, 49520, and 49525). For each procedure, we count the times the CPT was recorded as the principal procedure or as one of up to nine other procedures on outpatient discharge records, by hospital and year. Of the ICD-9-CM procedures in CCS 85, we excluded codes for femoral hernia repair and laparoscopic repair of inguinal hernia, and included 14 procedures used in the open repair of inguinal hernia (5300–5305 and 5310–5317).10 We count the times any of these 14 procedures appear as the principal procedure or as one of up to nine other procedures on inpatient discharge records, by hospital and year.
1598 HSR: Health Services Research 48:5 (October 2013) Table 1 reports descriptive statistics for open inguinal hernia repair surgeries by setting in our sample hospitals in 1999. Sample sizes vary by procedure (based on the availability of payment rate data) and by setting (based on the availability of discharge records).11 Panel A reports the mean number of times the procedure was performed in the outpatient setting as the principal procedure and as either the principal or other procedure. CPT 49505 is the most commonly used of the four outpatient procedures; the average hospital performed 24.6 surgeries involving that procedure in that year. Panel B reports the mean count of hernia procedures in the inpatient setting. There were 8.2 inpatient open inguinal hernia repair surgeries performed as the principal or other procedure per hospital in 1999.
Payment Rate Measures
We next construct hospital-specific Medicare payment rates to outpatient departments for each of the open inguinal hernia repair procedures described
above (CPTs 49505, 49507, 49520, and 49525). For the post-OPPS years, we obtain quarterly CMS publications reporting payments by ambulatory payment classification (APC) along with quarterly crosswalks from CPT to APC.12 We create hospital-specific measures by adjusting APC payment rates using the hospital wage index and we create annual measures by averaging the quarterly data.
To obtain hospital- and procedure-specific payments in the pre-OPPS years, we follow the algorithm developed in He and Mellor (2012) to impute hospital- and procedure-specific charges from the total charge field on the discharge record. The algorithm identifies CPT-specific charges for 58–94 percent of the hospitals in our sample depending on the CPT.13 Once we obtain procedure- and hospital-specific charges, we apply hospital-specific outpatient surgery payment-to-charge ratios imputed from 1997 to 1999 annual Medicare cost reports.
Figure 1 illustrates median Medicare payment rates (in 2008 dollars) over time for each of the four procedures. Median payment rates decreased by 4–10 percent between 1999 and 2004 (before and after the full phase-in of OPPS), and the majority of hospitals (51–60 percent, depending on the procedure) experienced a decrease in payment rate in this time period. About 40–45 percent of the procedure-specific within-hospital variation in payment rates over the 12 years in our sample occurs in the years around the implementation of OPPS, and a large portion (between 80–88 percent) of the 1999– 2004 payment variation represents decreases in payments from the prior year.
Indications for Use
Gentrix® Surgical Matrix Thin (3-layer) are intended for implantation to reinforce soft tissue where weakness exists in patients requiring urological, gastroenterological, or plastic & reconstructive surgery. Reinforcement of soft tissue within urological, gastroenterological, and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia and body wall repair, colon and rectal prolapse repair, tissue
repair, and esophageal repair. The Gentrix Surgical Matrix Thin minimizes tissue attachment to the device in case of direct contact with viscera.
Gentrix® Surgical Matrix (6-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia (e.g.: hiatal/diaphragmatic) and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair. The
Gentrix Surgical Matrix minimizes tissue attachment to the device in case of direct contact with viscera.
Gentrix® Surgical Matrix Plus (8-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following open or laparoscopic procedures: hernia (e.g.: hiatal/diaphragmatic) and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair. The Gentrix Surgical Matrix Plus minimizes tissue attachment to the device in case of direct contact with viscera.
Gentrix® Surgical Matrix Thick (8-layer) is intended for implantation to reinforce soft tissue where weakness exists in patients requiring gastroenterological or plastic & reconstructive surgery. Reinforcement of soft tissue within gastroenterological and plastic & reconstructive surgery includes, but is not limited to, the following procedures: hernia and body wall repair, colon and rectal prolapse repair, tissue repair, and esophageal repair.
Procedures: CPT Codes and Medicare Payments
Physician and Outpatient Facility
The following table contains CPT codes that may be utilized when reporting surgical procedures. Please check the current CPT manual for other codes that may be applicable. The table also includes the 2020 Medicare national unadjusted payment rates. Check with your MAC for payment rates specific to your region.
Correct Coding Initiative (CCI) Edits
Empire is increasing its compliance with industry standards by adopting the following code combinations from the Center for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (CCI) into our payment policy.
The National Correct Coding Initiative is a collection of bundling edits that are separated into two major categories: Comprehensive/Component Procedure Code edits and Mutually Exclusive Procedure Code edits.
Comprehensive/Component Procedure Code edits
Codes that are considered “Components” are incidental to the codes considered to be “Comprehensive” and will be denied as such. The table below lists the procedure that will be denied—”Deny Procedure”—as incidental to the corresponding “When Billed with Procedure.”
Mutually Exclusive Procedure Code edits
Mutually Exclusive Procedures are procedures that cannot be reasonably done in the same session. To be consistent with existing payment policy, when Mutually Exclusive procedures are billed for the same date of service, only the procedure with the highest relative value (“When Billed with Procedure”) will be allowed and the procedure with the lower relative value (“Deny Procedure”) will be denied as Mutually Exclusive of the other procedure.
In some situations, according to CMS, certain modifiers may be allowed to bypass these edits.
Deny Procedure When Billed with Procedure
38500 49505
49568 49505
Modifier 73 – Discontinued Outpatient Hospital Surgical Procedure/Service Prior to Anesthesia Administration
Used for surgical or radiological procedures in ASC. Due to extenuating circumstances or those that threaten the well‐ being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided and being taken to the room where the procedure is to be performed), but prior to the administration of the anesthesia.
** Used for procedures that require anesthesia.
** Used for an outpatient hospital procedure discontinued before the patient has been prepared for the procedure and/or before the induction of anesthesia whether local regional block(s) or general anesthesia.
** If none of the procedures were completed, report the first planned procedure with modifier 73. Patient must be wheeled to the room where the procedure is to be performed in order to report modifier.
** Do not use this modifier for the elective cancellation of a procedure.
** Do not use this modifier if the surgeon cancels or postpones the scheduled surgery because of a patient complaint such as a cold or flu upon intake.
** The physician should not use this modifier. This is only appropriate for use by the ASC.
Example: A 65‐year old male was brought to the OR for repair of a recurrent inguinal hernia. The patient was prepped and draped and positioning was carried out. Before the administration of anesthesia, the patient complained of chest pain. A cardiac monitor revealed ST segment changes. The procedure was cancelled and the reported CPT 49520‐73: Repair recurrent inguinal hernia, any age, reducible
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