Vol. 15 •Issue 20 • Page 10
Coding Corner Assigning Codes for Digestive System Procedures
Case Study 1
Preoperative Diagnosis: Incarcerated left inguinal hernia. Postoperative Diagnosis: Incarcerated direct left inguinal hernia; large lipoma of spermatic cord. Procedure Performed: Left inguinal herni-orrhaphy using Marlex mesh and lay-on, no tension technique.
Operative Technique: This 55-year-old male patient was prepped and draped in the usual sterile fashion, under general endotracheal anesthesia. An elliptical incision was made in the left groin and carried down to the aponeurosis of the external oblique. This was opened in the direction of its fibers, and a large lipoma of the cord was also noted and removed. The reflection of the peritoneum was identified just above the internal ring, and there was no evidence of indirect hernia.
There was a large direct hernia bulging. I decided to use a large Marlex mesh. This was placed in the hernial defect and sutured into place medially to conjoin tendon, laterally to PoupartÕs, superiorly to transversalis sling, and inferiorly to lacunar ligament. A lay-on graft was then placed underneath the spermatic cord in the usual fashion and sutured to the same landmarks. A slot was left for the passage of the spermatic cord. The external oblique was then closed over the lay-on mesh with the cord being in its normal anatomic position. ScarpaÕs fascia was closed with 3-0 subcuticular Vicryl suture, reinforced by Steri-Tapes.
The patient tolerated the procedure well and left the operating room in good condition.
ICD-9-CM Diagnosis Codes
Preoperative ICD-9-CM Diagnoses: In-carcerated left inguinal hernia
Preoperative ICD-9-CM Diagnosis Code:
550.10 Inguinal hernia with obstruction, no gangrene, unilateral/unspecified
Postoperative ICD-9-CM Diagnosis: In-carcerated direct left inguinal hernia; lipoma of spermatic cord
Postoperative ICD-9-CM Diagnosis Codes:
550.10 Inguinal hernia with obstruction, no gangrene, unilateral/unspecified
214.4 Lipoma of spermatic cord
CPT Codes and Rationale
In the diagnosis, the surgeon states that the hernia is incarcerated. The procedure was performed by open incision vs. laparoscopy, and the patient is over 5 years of age. You should refer first to the term Hernia Repair in the CPT manual index. Checking the list of items that follow and comparing with the above documentation you will see that you should choose the term Inguinal. The first indented term under Inguinal is Incarerated, which is the documented procedure. Codes 49492, 49496 and 49501 are listed there. After checking the descriptions of these codes you will see that the following is the correct code.
49507 Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated The surgeon also stated that a large lipoma of the cord (spermatic) was present and that it was excised. In the CPT manual index, you will refer to the term Excision. Checking the list under this term, you will see Lesion. Indented under this term is Spermatic Cord É 55520. Reading the codeÕs narrative description will confirm that you have made the correct choice.
55520 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
Even though code 55520 is listed as a separate procedure, it was performed with an inguinal hernia repair. Therefore, neither procedure is considered an inherently inclusive component of the other. It is appropriate to assign the CPT code for the inguinal hernia repair and the excision of the lipoma of the spermatic cord with modifier 59 (distinct procedural service) to communicate this.
The following codes should be assigned for both the facility and the professional components. As stated above, assign modifier 59 (distinct procedural service) only to the code 55520. 49507 Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated 55520-59 Excision of lesion of spermatic cord (separate procedure)
Case Study 2
Preoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone.
Postoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone.
Procedured Performed: Excision of mass lesion.
Operative Technique: After adequate general anesthesia was obtained, an incision was made overlying the 1.0 cm. cystic mass of the soft palate at the retromolar trigone. The incision was made overlying the mass, and by sharp and blunt dissection with the Metzenbaum scissors, the cystic mass was circumferentially dissected from the surrounding tissue and excised en bloc, intact and was sent to the pathology department.
We obtained hemostasis with two figure-eight suture ligatures of 3-0 Chromic Catgut and cautery with the suction Bovie unit. The wound was then closed with interrupted sutures of 3-0 Chromic Catgut. The patient tolerated the procedure well and left the operating room in good condition.
ICD-9-CM Diagnosis Codes
Preoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone ICD-9-CM Diagnosis Code:
528.9 Other and unspecified disease of oral soft tissues
Postoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone
ICD-9-CM Diagnosis Code:
528.9 Other and unspecified disease of oral soft tissues
CPT Code Assignments and Rationale
The surgeon states that the mass is excised en bloc and sent to pathology. The wound is then repaired with sutures.
Refer to the term Excision in the CPT manual index and then the term Lesion. Checking the list under this term, you will see the term Palate followed by codes 42104Ð42120. After reading the narrative description of these codes, you will see that the correct choice is 42106. This is the correct code assignment for both the facility and professional components.
42106 Excision, lesion of palate, uvula; with simple primary closure
Susan Howe is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.
