Vol. 17 •Issue 24 • Page 11
Coding Corner
Coding for the Digestive System
If the procedure identified by code 55520 is performed with an inguinal hernia repair (49507), it is appropriate to assign both codes. Add modifier 59 (distinct procedural service) to 55520.
Preoperative diagnosis:Incarcerated left inguinal hernia.
Postoperative diagnosis:Incarcerated direct left inguinal hernia and 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 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 noted. This lipoma was 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 this was 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. Omentum was found in the hernia sac and this was removed from the sac and reduced back in place. 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 DIAGNOSES
Preoperative: Incarcerated left inguinal hernia
550.10 Inguinal hernia with obstruction, no gangrene, unilateral/unspecified
Postoperative: Incarcerated direct left inguinal hernia and lipoma of spermatic cord
550.10 Inguinal hernia with obstruction, no gangrene, unilateral/unspecified
214.4 Lipoma of spermatic cord
CPT CODE ASSIGNMENTS 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 older than 5 years of age.
In the index, look up the terms Hernia Repair, followed by Inguinal and then Incarcerated 49492, 49496, 49501, 49507, 49521. Read the descriptions of these codes under “Repair” in the digestive system subsection of the Surgery section of the CPT Manual, and you will see that the code below is the correct choice:
49507 Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated
In the documentation, the surgeon also stated that a large lipoma of the (spermatic) cord was present, and this was excised. Refer to the term Excision in the CPT manual index and then Lesion and Spermatic Cord — 55520.
The code listed is the correct choice.
55520 Excision of lesion of spermatic cord (separate procedure)
As you see above, the narrative description states that this code is listed as a separate procedure. However, in spite of this, if this procedure is performed with an inguinal hernia repair, neither procedure is considered an inherently inclusive component of the other. Therefore, it is appropriate to assign the CPT code for the inguinal hernia repair and the excision of the lipoma of the spermatic cord and assign modifier 59 (distinct procedural service) to communicate this fact.
The code assignments for the technical (facility) and professional components are the same as listed below.
55520-59 Excision of lesion of spermatic cord (separate procedure)
49507 Repair initial inguinal hernia, age 5 years or over; incarcerated orstrangulated
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn®), St. Paul, MN.
