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Code This!

Scenario Week of September 04, 2014:
View Current Scenario

Assign the correct 2014 CPT and ICD-9-CM diagnosis codes for the following outpatient coding scenario.

Preoperative Diagnosis: Incarcerated right inguinal hernia

Postoperative Diagnosis: Incarcerated right inguinal hernia

Operation: Right inguinal herniorrhaphy with mesh

Anesthesia: General endotracheal

Complications: None

Blood Loss: 150 cc

Drains: Penrose drain was placed

Indications: This is a 41-year-old male patient who presents with a history of a right inguinal hernia which is incarcerated. This will be his initial hernia repair. The risks and benefits of the procedure were explained to the patient. I answered all of his questions, and the patient expressed understanding and consent for surgery.

Approach and Surgical Procedure: The patient was placed in the supine position on the operating room table, and after adequate induction of the endotracheal anesthetic the abdomen and scrotum was prepped and draped in a sterile fashion. A 10 cm transverse incision was made approximately two fingerbreadths above the inguinal ligament. The subcutaneous tissues were dissected with the electrocautery knife. The external oblique fascia was identified and divided laterally and then followed in the medial direction. A hemostat was placed on each side of the external oblique muscle. The inguinal nerve was identified and carefully dissected away from its surrounding tissues with a pair of Metzenbaum scissors. The inguinal nerve was then retracted out of the way. A peanut dissector was then used to dissect around both sides of the hernia sac and spermatic cord. The external ring, internal ring, and pubic tubercle were then identified. The hernia sac and spermatic cord were isolated by careful blunt finger dissection. A finger was placed through the internal ring, above the pubic tubercle. A Penrose drain was then placed to isolate these structures.

Several large cremasteric fibers were dissected with electrocautery knife. The hernia sac was then carefully identified by a combination of blunt dissection and sharp dissection. The hernia sac was then entered and the small bowel was visible within the hernia sac. The hernia sac was retracted medially and its attachments to the spermatic cord structures were carefully dissected away. The vas deferens was identified and preserved. Once the entire spermatic cord had been isolated from the hernia sac, the Penrose drain was removed from its previous position and placed around the spermatic cord. The spermatic cord was retracted laterally, while the dissection continued around the entire hernia sac to its base. The medial edge of the hernia sac was examined closely to rule out the presence of any bladder wall. There did not seem to be any evidence of bladder or other important structures within the hernia sac.

A 2-0 silk purse-string suture was placed high along the base of the sac. Upon tying the suture, care was taken not to entrap any intra-abdominal components. A second purse-string suture was placed above that one followed by a single stick tie. The hernia sac was then ligated above the sutures. Hemostasis was achieved with the electrocautery knife. At this point the spermatic cord was retracted superiorly and the hernia repair commenced from the medial aspect of the incision. The Prolene mesh was cut to size and tacked to the pubic tubercle periosteum with a #1 Novafil stitch.

The stitch was started along the medial aspect of the incision and carried inferiorly along the iliopubic tract and around the spermatic cord. The transversalis fascia was then used superiorly to complete our repair between the mesh and the transversalis fascia. The mesh was cut in such a fashion as to wrap around the spermatic cord allowing approximately 1 fingerbreadth space around the spermatic cord.

A single #1 Novafil stitch was placed in the mesh to tighten around the ring.

The internal oblique fascia was closed with a running #1 Novafil. The external oblique fascia was closed with a running #1 Novafil. The inguinal nerve was carefully observed to ensure no entrapment during the suturing process. The origin of this nerve was infiltrated with 0.25% Marcaine. The subcutaneous tissues were closed with a series of interrupted 3-0 Dexon sutures. The skin was then closed with a running 4-0 Dexon subcuticular stitch. Steri-Strips were applied and a sterile dressing was placed. The patient tolerated the procedure well with no intraoperative complications and was transferred to the recovery room in stable condition.

Operative Findings: Incarcerated right inguinal hernia, reduced intraoperatively. There was an indirect and direct component to the hernia. The small bowel was visualized within the hernia sac.

Please assign the correct CPT and ICD-9-CM codes for the procedure above.


ANSWERS

CPT Procedure Code
49507 Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated

Rationale: The procedure performed was the repair of an incarcerated right inguinal hernia. In the index of CPT 2014, under the main term “Hernia” and subterms “inguinal” and “incarcerated,” the codes provided are 49492, 49496, 49501, 49507, and 49521. A review of these codes in the main section of the book shows that the codes are defined by age and whether the hernia is an initial or recurrent. The documentation states that this was the patient’s initial hernia repair, so that excludes code 49521, which describes recurrent inguinal hernia repair. Next the documentation states the patient is 41 years old, so this excludes codes 49492, 49496, and 49501, which apply to patients 4 years old and younger. The code description for 49507 describes a repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated. The physician’s documentation supports reporting this procedure.

The use of mesh is not reported separately except when incisional hernia repairs (49560-49566) are performed. So in this case, an inguinal was repaired so the mesh implant is an integral component of the procedure.

ICD-9-CM Diagnosis Code
550.10 Inguinal hernia, with obstruction, without mention of gangrene unilateral or unspecified (not specified as recurrent)

Rationale: The diagnosis for the surgical procedure is an incarcerated right inguinal hernia. In the ICD-9-CM alphabetic index, under the main term “Hernia” and subterm “incarceration,” the coder is directed to “see also hernia by site, with obstruction.” When subterms “inguinal” and “with obstruction” are referenced, the coder is directed to code 550.1. An additional fifth digit is required from “0 unilateral or unspecified (not specified as recurrent),” “1 unilateral or unspecified, recurrent,” “2 bilateral (not specified as recurrent),” or “3 bilateral, recurrent.” The physician’s documentation states this is the patient’s initial hernia repair and the hernia is only on the right side, so the appropriate fifth digit would be zero. When code 550.10 is referenced in the tabular section of ICD-9-CM Volume 1, the code description states “Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified (not specified as recurrent).” Also under the code description it states this code applies to an “inguinal hernia with mention of incarceration, irreducibility, or strangulation”; therefore, this would be the correct code assignment.

 
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