American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Did You Know? Coding Tip: Ventral Hernia Repair

Ventral incisional hernia repairs, like inguinal repairs, are reported as initial or recurrent and as reducible or incarcerated/strangulated. Although there are four codes for the four different types and degrees of difficulty of ventral incisional hernias, there is no differentiation in CPT at this time for the size of the hernia. Repair of a one-centimeter incarcerated incisional hernia is reported with the same CPT code as a 25-centimeter incarcerated incisional hernia, and both receive the same 15.38 wRVU value regardless of the difference in operative time and effort. In this respect, ventral hernia repair coding differs from many other areas of CPT, such as wound repair or subcutaneous lesion excision. Also, multiple ventral hernias repaired at the same operation through the same incision cannot be coded separately. Multiple holes in a “Swiss cheese” abdominal wall count (for reimbursement) as a single incisional hernia repair.

None of the open ventral hernia codes were valued to include the placement of mesh because when the codes were created, the dominant practice was primary tissue repair. There is a separate add-on code, 49568, for the implantation of mesh or other prosthesis for open incisional or ventral hernia repair. This code is a restricted add-on code, meaning that it can only be billed with certain base codes. This code can be used with CPT codes 49560–49566 for open repair of ventral or incisional hernia but cannot be combined with other codes (for instance, with 49580-49587, repair of umbilical hernia, even though these codes were valued for primary suture repair). It also cannot be reported with laparoscopic ventral hernia repair (49652–49657) because these codes, unlike the open ventral hernia repair codes, were valued to include mesh placement.

For an in-depth analysis of many of the issues surrounding coding and reimbursement, look for Coding and Reimbursement for Surgeons by Mark Savarise, MD, FACS, and Christopher Senkowski, MD, FACS, which will be published by Springer in the fall of 2016.