Procedure Code 49505, 49560, 49585

49505 Repair initial inguinal hernia, age 5 years or older; reducibleDigestive System

CPT Codes 40000-49999

Correspondence Language Policy/Example Number 2.40000 - HCPCS/CPT procedure code definition

For example, the code descriptor for CPT code 45805 is “Closure of rectovesical fistula; with colostomy” and the code descriptor for CPT code 45800 is “Closure of rectovesical fistula;”. Therefore, based upon the code descriptors the procedure described by CPT code 45800 is a component of the procedure described by CPT code 45805, and CPT code 45800 is bundled into CPT code 45805.

Correspondence Language Policy/Example Number 3.40000 - CPT Manual or CMS manual coding instruction

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).

Correspondence Language Policy/Example Number 4.40000 - Mutually exclusive procedures

For example, CPT codes 43100 and 43101 describe different approaches to the excision of an esophageal lesion. CPT code 43100 describes a cervical approach, and CPT code 43101 describes a thoracic or abdominal approach. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.40000 - Sequential procedure

For example, if an anoscopy with control of bleeding (CPT code 46614) is unsuccessful and is followed by a complex or an extensive internal and external hemorrhoidectomy (CPT code 46260), only CPT code 46260 may be reported. Therefore, CPT code 46614 is not separately reportable with CPT code 46260.

Correspondence Language Policy/Example Number 6.40000 – CPT “separate procedure” definition

For example, the code descriptor for CPT code 44005 (“Enterolysis (freeing of intestinal adhesion) (separate procedure)”) includes the “separate procedure” designation. When a partial colectomy with anastomosis (CPT code 44140) is performed, the procedur described by CPT code 44005 does not meet the definition of a “separate procedure”. Therefore, CPT code 44005 cannot be reported separately and is bundled into CPT code 44140.

Correspondence Language Policy/Example Number 7.40000 - More extensive procedure

For example, CPT code 42426 describes excision of a parotid gland tumor with radical neck dissection. CPT code 42425 describes excision of a parotid gland tumor without a radical neck dissection. The procedure described by CPT code 42426 is more extensive than the procedure described by CPT code 42425. Therefore, CPT code 42425 is bundled into CPT code 42426.

Correspondence Language Policy/Example Number 10.40000 - Standards of medical/surgical practice

For example, during a tonsillectomy (CPT code 42821) bleeding may occur. The control of such bleeding intraoperatively is a standard of surgical practice. It is inappropriate to report separately CPT code 42961 (control of oropharyngeal hemorrhage). Therefore, CPT code 42961 is bundled into CPT code 42821.

Correspondence Language Policy/Example Number 11.40000 - Anesthesia service included in surgical procedure

For example, if an ilioinguinal or iliohypogastric nerve block (CPT code 64425) is performed for anesthesia by the physician performing an inguinal hernia repair (CPT code 49505), the nerve block is included in the surgical procedure and is not reported separately. Therefore, CPT code 64425 is bundled into CPT code 49505.

49505 HERNIA REPAIR INGUINAL (Groin) without Mesh implant (patient is 5 years or older)

Procedure code 49505, 49560, 49585

procedure code and description

49505 - Repair initial inguinal hernia > 5 yrs. or over, reducible, under 5 years - average fee payment - $590 - $600

49560 Repair initial incisional or ventral hernia; reducible $946

49561 Repair initial incisional or ventral hernia; incarcerated or strangulated $1,292

49585 Repair umbilical hernia, age 5 or older; reducible

49587 Repair umbilical hernia, age 5 or older; incarcerated or strangulated

Primary hernias

General surgeons usually repair initial hernias, and it is unusual for plastic surgeons to be involved in these primary procedures except in unusual circumstances.

Hernias are either reducible or incarcerated, and separate codes are used to report these situations. If a primary hernia is reducible and it is repaired, code 49560 is used. If the primary hernia is incarcerated, the repair is reported with code 49561. The herniorrhaphy codes are global and include isolation and dissection of the hernia sac, reduction of intraperitoneal contents, fascial repair and soft tissue closure.

If a synthetic mesh is used to bridge or reinforce the fascial tissues, then the add-on code, 49568, is reported in addition to the code for the hernia repair. As with all add-on codes, 49568 is never reported alone and does not take the multiple procedure, "-51," modifier. Thus, the repair of a primary reducible incisional hernia that requires the use of a Marlex® mesh is coded:

49560 Herniorrhaphy, primary, reducible

49568 Implantation of Marlex mesh

Recurrent hernias

Procedures for recurrent hernias are often more complex and occasionally require the involvement of a plastic surgeon, as tissues may be attenuated or absent.

If the recurrent hernia is reducible, the herniorrhaphy is reported with code 49565; if the recurrent hernia is incarcerated, code 49566 is used. Use of synthetic mesh is reported with add-on code 49568 in addition to the herniorrhaphy code. 

If insufficient fascial tissue is available for closure, incisions may be made in the posterior rectus sheath to allow for advancement of tissues medially. No specific code exists for this maneuver, but this does fall into the realm of complex repair. 

This is an additional surgical procedure performed prior to the layered closure (a defect "requiring more than layered closure"), so it is considered a complex repair.

Consider the repair of a recurrent, incarcerated hernia. The sac is dissected and the abdominal contents are reduced. Bilateral longitudinal incisions (each 20 cm. long) are made in the posterior rectus sheaths to facilitate fascial advancement prior to fascial and soft tissue repair. This procedure is coded:

43566 Herniorrhaphy, recurrent, incarcerated

Anesthesia service included in surgical procedure

For example, if an ilioinguinal or iliohypogastric nerve block (procedure code 64425) is performed for anesthesia by the physician performing an inguinal hernia repair (procedure code 49505), the nerve block is included in the surgical procedure and is not reported separately. Therefore, procedure code 64425 is bundled into procedure code 49505.

For example, the code descriptor for procedure code 45805 is “Closure of rectovesical fistula; with colostomy” and the code descriptor for procedure code 45800 is “Closure of rectovesical fistula;”. 

Therefore, based upon the code descriptors the procedure described by procedure code 45800 is a component of the procedure described by procedure code 45805, and procedure code 45800 is bundled into procedure code 45805.

For example, the procedure Manual instruction above procedure 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, procedure code 49568 (mesh implantation) should not be reported separately with procedure code 49505 (inguinal hernia repair).

New Edit #805 49585 bundles with 43880

Rationale: The performance of an abdominal procedure includes the reimbursement for hernia repair. The CMS National Correct Coding Manual states: “If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., procedure 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 is not medically reasonable and necessary and should not be reported separately.” Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed.

Rationale

Anthem Central Region bundles procedure 49585 as incidental to procedure 43880. The performance of an abdominal procedure includes the reimbursement for hernia repair. The CMS National Correct Coding Manual states:

“If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., procedure 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 is not medically reasonable and necessary and should not be reported separately.” Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed.