Coding, Classification & Reimbursement

Planned hernia repair, but no hernia found.

  • 1.  Planned hernia repair, but no hernia found.

    Posted 02-07-2019 10:32
    ​I am having trouble determining which CPT code to use for the following Operative report:
    PREOPERATIVE DIAGNOSIS: Right inguinal hernia, right inguinal mass, hernia versus lymphadenopathy.
    POSTOPERATIVE DIAGNOSIS: Right inguinal adenopathy.
    FINDINGS: The inguinal canal and cord were explored and did not contain hernia.
    DETAILS OF PROCEDURE: ….The incision was made in the right inguinal region at the external ring area. The fascia was incised, and the cord was exposed. Very diligent and careful dissection of the cord and floor revealed no evidence of any hernia sac. At this juncture, our attention was focused toward the inguinal node area that would be the superficial inguinal node area just beneath the external ring, and indeed, there were enlarged lymph nodes. One of them was dissected free with the lymph channel being ligated using a 2-0 Vicryl figure-of-eight suture. When it was clear that there was no oozing and the lymph node had been sampled, the external oblique was reapproximated using a 2-0 Vicryl. This was the external oblique of the hernia region…..
    I have been looking at CPT 49010 Exploration, Retroperitoneal Area w/wo Bx(s) (Sep Proc).  It would include exploring for the inguinal hernia and includes biopsies, but not sure if lymph node biopsies would be included in this?
    I have also been considering just billing for the lymph node procedure and coming up with 38531, 38760, OR 38500, but having trouble determining if the lymph nodes were just biopsied or completely removed.  I do not have a pathology report back yet.

    I greatly appreciate any advice!

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    Renee Fischer, RHIT
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  • 2.  RE: Planned hernia repair, but no hernia found.

    Posted 02-10-2019 15:29
    Is this outpatient or Pro Fee?  What does the path report say?
    You might have to go with lymphadenopathy.

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    Nikki Becker, BBLM, RHIT, CCS
    Remote Inpatient Medical Coder
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  • 3.  RE: Planned hernia repair, but no hernia found.

    Posted 02-16-2019 16:27
    ​Hello Renee,

    For hospital outpatient accounts I fee that you could code for the planned procedure.  The procedure would fall into an unsuccessful procedure - see info below from CC for HCPCS.

    Discontinued vs unsuccessful procedures

    Coding Clinic for HCPCS - Third Quarter 2007 Page: 10

    Related Information

    Discontinued procedures vs. unsuccessful procedures


    Surgery is an operation or procedure that is performed for treatment of an injury, deformity, disease or condition, by manual or instrumental means.

    There are many techniques utilized for surgery, such as cutting, abrading, suturing, and laser. However, not every operation or procedure has a successful outcome.

    The Central Office on HCPCS has received several questions regarding whether an unsuccessful operation or procedure should be reported. In response to these questions, this article is being written to provide some direction in the coding and reporting of unsuccessful operations or procedures.

    When a procedure is considered to have "failed," specifically the expected result of the procedure is not achieved, the procedure is coded as performed.

    Although, the procedure might be described as a failed procedure, in all actuality the procedure was performed and therefore should be coded.

    Sometimes several unsuccessful attempts are made during the same operative episode to perform a procedure and finally the last attempt is successful.

    In this instance, only one unit of a single code would be reported for the procedure successfully accomplished, regardless of the numerous attempts.

    The unsuccessful attempts are considered a part of the successful procedure.

    Discontinued procedures vs. unsuccessful procedures

    The term "unsuccessful procedures" is sometimes used interchangeably with "discontinued procedures." Coders should understand that there is a difference between an unsuccessful procedure and a procedure that has been discontinued. An unsuccessful procedure would be a procedure that was performed but did not achieve the desired results.

    A discontinued procedure means that the patient was taken to the treatment room for a planned procedure and/or the procedure was initiated, but for some specific reason the procedure was either cancelled or not completed.

    Similar to the unsuccessful procedure, the specific discontinued procedure would be coded, but the difference is that a modifier (i.e., 52, 73, or 74) would be appended to the code to report that the procedure or service was reduced, discontinued, or cancelled at the physician's discretion before or after the administration of anesthesia, if applicable. For additional information regarding discontinued procedures, see Coding Clinic for HCPCS, First Quarter 2007, pages 1-3.

    To ensure that the unsuccessful or discontinued procedure is reported correctly, the coder must review the documentation thoroughly to identify whether the procedure was planned and/or started but cancelled/discontinued or the procedure was completed but the desired results were not achieved. If the documentation is unclear, the physician must be queried for clarification.

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    Lisa Withers
    Coding Qi Compliance Auditor and Trainer
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