Mesh placement may be common during hernia repair, but you can only bill separately for the procedure in a minority of cases. Make sure you know what they are.
In addition, you should be aware that recurrent hernia repair usually includes mesh removal, unless the physician can document extraordinary effort.
1. Claim Placement With Incisional/Ventral Hernia
You may report separate placement of mesh (+49568, Implantation of mesh or other prosthesis for incisional or ventral hernia repair) only when the surgeon repairs an incisional or ventral hernia, says Kathleen Mueller, RN, CPC, CCS-P, a registered nurse and reimbursement and coding specialist in Lenzburg, Ill.
Get the specifics: You may report 49568 with 49560 (Repair initial incisional or ventral hernia; reducible), 49561 (... incarcerated or strangulated), 49565 (Repair recurrent incisional or ventral hernia; reducible) and 49566 (... incarcerated or strangulated) when the surgeon documents mesh placement during the hernia repair.
2. Skip Separate Placement Code for All Others
For any hernia repairs not listed above--including epigastric, umbilical, spigelian and inguinal hernia repairs (49570-49651)--you should not separately report 49568, regardless of whether the surgeon places mesh during the repair. The National Correct Coding Initiative recently solidified this guideline by bundling 49568 into all hernia repairs 49570-49651.
Example: "If the operative report documents, 'Repair of epigastric hernia [for instance, 49570, Repair epigastric hernia (e.g., preperitoneal fat); reducible (separate procedure)] with marlex mesh,' the mesh isn't separately billable because you can only add 49568 to 49560, 49561, 49565 or 49566," Mueller says.
3. Removal + Repair = No Separate Payment
If the surgeon removes infected mesh placed during a previous hernia repair when making a recurrent hernia repair, you generally cannot code separately--or receive reimbursement--for the mesh removal.
Although you may be tempted to report an unlisted- procedure or foreign-body-removal code for mesh removal with recurrent repair, this is inappropriate.
"Keep in mind that the surgeon is already getting paid more for using the 'recurrent' code," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CEO of Coding and Reimbursement Network Inc., in Egg Harbor City, N.J. "The payer expects the recurrent repair to be more work than an initial repair due to scar tissue, adhesions and mesh issues."
Bottom line: Codes for recurrent repairs (for example, 49520, Repair recurrent inguinal hernia, any age; reducible) include as an integral component removal of mesh placed during a previous hernia repair.
Modifier 22 Provides an Option
When removing mesh requires truly extensive effort, you may be able to gain additional reimbursement by appending modifier 22 (Unusual procedural services) to the appropriate recurrent hernia repair code. But, be prepared to back your claim up with extensive documentation.
"You just don't get extra money for [mesh removal] unless the physician really documents very well, and there are lots of problems beyond simply dissecting away the old mesh," says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.
Example: During recurrent inguinal repair on a 55-year-old patient, the surgeon must remove mesh placed during the previous repair. The area of the previous repair shows extensive scarring and infection, and the mesh removal requires 40 minutes longer than average to complete.
In this case, you can append modifier 22 to 49520. Include a full operative report and a cover letter describing precisely that the extra time was required to remove the mesh, along with a request for additional compensation.
Learn more: Look to an upcoming edition of General Surgery Coding Alert for complete information on modifier 22 claims.
4. Removal Only Means Unlisted Procedure
You can report mesh removal separately in some circumstances, Bucknam says.
"I would recommend an unlisted-procedure code if you have mesh removal without repair of a new hernia--for example, when the patient has erosion of the skin over the mesh or some pain related to the implant," she says.
For procedures of this type, you'll most likely report 49999 (Unlisted procedure, abdomen, peritoneum and omentum) with a diagnosis of 996.60 (Infection and inflammatory reaction due to unspecified device, implant and graft). You will have to provide the payer with complete documentation to describe the procedure.
One to avoid: CPT +11008 (Removal of prosthetic material or mesh, abdominal wall for necrotizing soft tissue infection [list separately in addition to code for primary procedure]) seems perfect to describe removal of mesh, either with or without hernia repair. But 11008 is an add-on code for use with 11004-11006 only. These codes describe extensive debridement performed on high-risk patients for conditions such as Fournier's gangrene (608.83).
In other words: You should not report 11008 for removal of infected mesh only, or for mesh removal with any hernia repair.