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Over the years, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) Specialty Society RVS Update Committee (RUC) have identified Current Procedural Terminology* (CPT) codes that are performed less than 50% of the time in the inpatient setting and that include inpatient hospital evaluation and management (E/M) services codes in the CMS physician time and visit database. The intent of this site-of-service anomaly screen was to determine if the work relative value units (wRVUs) for procedures were potentially misvalued because the codes included inpatient E/M visit codes even though the procedures typically were performed in an outpatient setting. The concern was that the payment should reflect the typical patient, and if the typical patient has a facility status of outpatient, then the wRVUs and time/visit database may not include inpatient E/M services codes. The most recent review of codes using the site-of-service anomaly screen identified codes for reporting abdominal hernia repair. The ACS and other stakeholder societies took the following steps to avert potential underpayment for hernia repair procedures resulting from the CMS “typical patient” payment policy.
Site-of-Service Anomaly Screen
The first RUC and CMS review of codes identified by the site-of-service anomaly screen resulted in a 7% to 12% decrease in wRVUs for seven open and laparoscopic hernia repair codes for 2012. More recently, code 49565, Repair recurrent incisional or ventral hernia; reducible, was identified by the RUC as a service performed less than 50% of the time in the inpatient setting that included inpatient hospital E/M service codes and had Medicare utilization of more than 5,000 paid claims. Although only code 49565 was identified under the screen’s criteria, both the RUC and CMS currently require review of all family codes when one or more codes are identified as potentially misvalued. This means that all open and laparoscopic hernia codes would need to be reviewed for physician work.
The ACS, Society of American Gastrointestinal and Endoscopic Surgeons, and American Society of Colon and Rectal Surgeons determined that payment for the typical hernia repair patient will result in all codes being under-reimbursed. Said another way, if 60% of patients were discharged the same day or the next day as outpatient, then all claims would be reimbursed as if all patients were outpatient because that was typical. Instead of submitting to a physician work review of code 49565 and related family codes, which likely would result in significant wRVU decreases based on the typical patient policy, the three societies recommended referring the codes to CPT to update the codes. This better describes hernia repair procedures as performed in current practice, taking into consideration the use of mesh, hybrid procedures, and length of stay.
Mesh Implantation or Excision
Literature supports implantation of mesh as typical for both open and laparoscopic/robotic hernia repair procedures, along with other abdominal procedures. Coders frequently ask how to report the significant work for mesh removal when performing an initial or recurrent abdominal hernia repair, because mesh implantation is not included in the current work value for these procedures. Mesh implantation and removal with stomal hernia repair also is a common coding question. Consequently, any changes to hernia repair coding required consideration of the use and removal of mesh.
Hybrid Procedures
The stakeholder societies and the AMA recently have received coding questions about correct reporting for “hybrid” abdominal hernia repair procedures where parts of the procedure are performed via an open approach and parts of the procedure use laparoscopy and/or a robot. These are not laparoscopic procedures converted to open procedures, but instead procedures that may start via an open approach and finish using a laparoscopic/robotic approach under pneumoperitoneum. A column in the June 2019 issue of the Bulletin clarified questions regarding correct coding for hybrid procedures. This was in response to changes to the International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10-PCS) codes that classify procedures for facility reporting that do not correspond to CPT coding (closed, percutaneous, open, laparoscopic).†
Consequently, any changes to hernia repair coding required consideration of the approach, including a hybrid approach.
Size, Number, and Type of Hernia Defect(s)
It is important to differentiate the total size of a hernia defect, as this affects the total physician work. For example, current coding for repair of a “Swiss cheese” incisional hernia that has a large total defect is coded the same as a single small incisional hernia. In addition, the repair of anterior abdominal hernias (i.e., epigastric, incisional, ventral, umbilical, spigelian) and parastomal hernias is similar.
Global Period Consideration
A global period of 0 days was recommended and accepted for new primary anterior abdominal hernia repair codes, a change that will allow correct reporting of hospital and office E/M visit codes in the postoperative period. For example, if the patient stays overnight and is discharged the next day, CPT code 99238 or 99239 can be reported for discharge management on the day after the procedure. On the other hand, if the patient is admitted and stays 5 days in the hospital, the surgeon can report an inpatient E/M visit code for each hospital day that a visit occurs. If this family of codes retained a 90-day global assignment, only the reduced work for outpatient discharge management would be included in the 90-day global payment since the typical patient for most hernia repairs is an outpatient. In addition, because the codes will have a 0-day global assignment, additional procedures (wound debridement, suture/staple removal) will be separately reportable even if the procedure does not require a return to the operating room (OR).
Summary of 2023 CPT Coding Changes
For 2023, CPT approved significant coding changes, as summarized in this column. The full 2023 CPT code descriptors are presented in Table 1.
- Delete codes 49560–49590, which describe open repair of anterior abdominal hernias
- Delete codes 49652–49657, which describe laparoscopic repair of anterior abdominal hernias
- Delete add-on code 49568, which describes implantation of mesh for open ventral/incisional hernias and defects resulting from necrotizing soft tissue infection
- Add 12 new codes (49591–49596 and 49613-49618)‡ to report anterior abdominal hernia repair by any approach (i.e., open laparoscopic, robotic), further by initial or recurrent hernia, further by total defect size, and further by reducible or incarcerated/strangulated
- Add two new codes (49621–49622)‡ to report parastomal hernia repair by any approach (i.e., open laparoscopic, robotic), further divided by reducible or incarcerated/strangulated
- Add one new add-on code (49623)‡ for removal of mesh/prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair
- Add one new code (15778)‡ for implantation of absorbable mesh or other prosthesis for delayed closure of external genitalia, perineum, and/or abdominal wall defect(s) due to soft tissue infection or trauma
- Add two new add-on codes (15853–15854)‡ for removal of sutures/staples not requiring anesthesia, to be reported separately in addition to an E/M code
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