Vol. 12 •Issue 6 • Page 8
Coding Corner
Case Studies: Digestive System Procedure
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 herniorrhaphy using Marlex mesh and lay-on, no tension technique
Operative Technique: This 55-year-old male 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 noted and removed. The reflection of the peritoneum was identified just above the internal ring, but 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 Poupart’s 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. Scarpa’s 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 Code Assignments
Preoperative Diagnosis and Code Assigned: Incarcerated left inguinal hernia
550.10 Inguinal hernia with obstruction, no gangrene, unilateral/unspecified
Postoperative Diagnoses and Codes Assigned:
•Incarcerated direct left inguinal hernia
•Lipoma of spermatic cord
550.10 Inguinal hernia with obstruction, no gangrene, unilateral/unspecified
214.4 Lipoma of spermatic cord
CPT Code Assignments
The surgeon states in the diagnosis that the hernia is incarcerated. The procedure was performed by open incision vs. laparoscopy, and the patient is over five years of age. In the CPT manual index, look up the terms Hernia, Repair, Inguinal and Incarcerated. After checking the descriptions of the four codes listed, you will see that the correct code is 49507.
The surgeon also stated that a large lipoma was present of the cord (spermatic), and this was excised. In the CPT manual index, check the terms Excision, Lesion and Spermatic Cord. Code 55520 is listed, and when you read the narrative description, you will see that this is the correct code.
You also will see that code 55520 is listed as a separate procedure. However, neither of the procedures performed in the case above would be considered an inherently inclusive component of the other because the one was done with an inguinal hernia repair. Therefore, it is appropriate to assign the CPT code for the inguinal hernia repair and the excision of the lipoma of the spermatic cord.
Also assign modifier 59 (distinct procedural service) to communicate this fact. Modifier LT (left side) would be assigned to both of the CPT codes reported to communicate that the hernia repair and the lipoma were performed on the left side.
For facilities, assign these CPT codes.
49507-LT Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated
55520-59-LT Excision of lesion of spermatic cord (separate procedure)
For professional services, assign these codes.
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 Two
Preoperative Diagnosis: Right inguinal hernia
Postoperative Diagnosis: Right inguinal hernia, direct
Indications for Procedure: This 55-year-old male has had a symptomatic hernia for more than a year and presents for repair. Pre-viously, he had an open left inguinal hernia repair, and we found no symptoms on this side.
Operative Technique: The patient was brought to the general operating room and placed supine on the table. After induction of uneventful general anesthetic, the patient’s abdomen was prepped and draped in the usual sterile fashion. Marcaine was infiltrated below the umbilicus, and a linear incision was made and carried down to the fascia, which was tented up.
Under direct vision, the fascia and peritoneum were entered. An 11-millimeter trocar was placed under direct vision, and the abdomen insufflated to a pressure of 15. The camera was then introduced, and the inguinal area was inspected. There was colon over the left side and, on the right side, a moderate-size direct inguinal hernia.
At this time an 11-millimeter trocar was placed to the left of the left rectus muscle at the level of the umbilicus, and a 5-millimeter trocar was placed to the right of the rectus muscle at the level of the umbilicus. Repair of the hernia was then undertaken. Using endoshears, the peritoneum above the hernia was incised. The hernia was then reduced using a mixture of blunt and sharp dissection. Following this, the Cooper’s ligament was identified, and superior and inferior flaps were created. The mesh was placed over the defect and secured in place using hernia stapler to the Cooper’s ligament and to the transversalis muscle on the superior aspect; all were done medially and laterally.
The pressure was let down to 15, the edges of the peritoneum were reapproximated using the hernia stapler, and the trocars were removed. The two larger sites were closed using 0-Vicryl to close the fascia, and the skin was closed at all sites using Dermabond. Once completed, the patient was awakened from anesthetic and taken to the recovery room in stable condition. He tolerated the procedure well with minimal blood loss. Sponge and lap counts were correct at the termination of the procedure.
ICD-9-CM Code Assignments
Preoperative ICD-9-CM Diagnosis: Right inguinal hernia
Postoperative ICD-9-CM Diagnosis: Right inguinal hernia, direct
Preoperative and Postoperative Code Assigned:
550.90 Inguinal hernia without obstruction/gangrene, unilateral/unspecified
CPT Code Assignments
The surgeon stated that the procedure was performed laparoscopically. The patient previously had hernia repair on the left side, but the right-sided hernia was new (initial). In the CPT manual index, check under the terms Hernia, Repair, Inguinal and Laparos-copic. You will see that the code range listed is 49650 to 49651. After reading the descriptions, it is clear that the correct code is 49650. Assign modifier RT (right side) to the facility code to communicate that the hernia repaired was in the right inguinal area.
For facilities, assign this code.
49650-RT Laparoscopy, surgical; repair initial inguinal hernia
For professional services, assign this code.
49650 Laparoscopy, surgical; repair initial inguinal hernia
Peggy Hapner is HIM consulting division manager for Medical Learning Inc. (MedLearn), St. Paul, MN.
