Mesh is expensive, as are the open and laparoscopic hernia repair procedures in which they're used. Depending on material, thickness and the intricacy of the manufacturing process, hernia mesh can cost as much as $20 per square inch. Here's how to ensure you get paid for implanting it.
The codes and how to use them
There are five CPT codes specific to mesh:
- 49560 - Repair initial incisional or ventral hernia; reducible
- 49561 - Repair initial incisional or ventral hernia; incarcerated or strangulated
- 49565 - Repair recurrent incisional or ventral hernia; reducible
- 49566 - Repair recurrent incisional or ventral hernia; incarcerated or strangulated
- 49568 - Implantation of mesh or other prosthesis for incisional or ventral hernia repair
According to the 2004 CPT code book (paragraphical note above code 49491), you should list code 49568 separately when mesh is used in addition to codes 49560, 49561, 49565 and 49566 for incisional or ventral hernia repair.
Don't, however, use code 49568 if your surgeon implants mesh laparoscopically. The appropriate method of reporting a laparoscopic incisional hernia repair with implantation of mesh is with the unlisted laparoscopic hernia repair code 49569, according to the September 2001 CPT Assistant newsletter from the AMA.
Sample op report
Now let's take a look at a sample report to demonstrate how to use CPT codes 49565 and 49568.
- OPERATION: Mesh repair of recurrent incisional hernia.
- ANESTHESIA: Local standby.
- PRE-OPERATIVE DIAGNOSIS: Recurrent incisional hernia.
- POST-OPERATIVE DIAGNOSIS: Recurrent incisional hernia.
- OPERATIVE INDICATIONS: This 58-year-old patient had a previous incisional hernia repair 26 years ago and developed a recurrence five fingerbreadths below and two fingerbreadths to the right of the midline. Repair was advised.
- OPERATIVE PROCEDURE: The patient was brought to the operating room, and after satisfactory general endotracheal anesthesia was obtained, was prepared and draped in the usual fashion. A horizontal incision over the area of the hernia defect was made through the skin and subcutaneous tissue. The bleeding points were controlled with the Bovie cautery and #3-0 Vicryl ties throughout. The hernia sac was identified, opened, and noted to contain omentum. The omentum was dissected free from the hernia sac, and replaced intraperitoneally. Segment of polypropylene mesh was placed under the dissected fascial edges of the defect and anchored in place with #4-0 Prolene sutures placed in a horizontal mattress fashion. The defect itself was then closed with interrupted figure-of-eight #0 Prolene sutures. The wound was irrigated with dilute antibiotic solution and local anesthetic. Subcutaneous tissue was closed with interrupted #3-0 Vicryl, and the skin was closed with a running #4-0 Vicryl subcuticular suture. Steri-Strips and a sterile occlusive dressing were positioned. The patient tolerated the procedure well and left the operating room in satisfactory condition.
- ESTIMATED BLOOD LOSS: 5cc, no replacement.
- DRAINS: None.
Your payment opportunities
Unless the mesh is used for incisional or ventral hernia repair, where add-on code 49568 can be reported to generate additional revenue, most payers don't provide additional reimbursement for the use of mesh. However, a savvy facility administrator will try to negotiate an additional payment or carve-out for the use of mesh - the negotiations may or may not be successful, but it's worth a try. There's no specific HCPCS Level II code for mesh that surgery centers can use, so I recommend you use A4649 (miscellaneous surgical supply).
An audit of a surgery center's coding identified two accounts in which the mesh application for incisional hernia (49568) wasn't coded and billed.
- A 55-year-old Custom Blue patient was seen for repair of incisional hernia with mesh. Code 49568 wasn't assigned for the mesh application.
- A 75-year-old Medicare patient was seen for an initial incisional hernia, which was inappropriately coded as a recurrent hernia (49565). Because this patient doesn't have a history of incisional hernia repair, the center should assign 49560 (repair of initial incisional hernia).?In addition, code 49568 wasn't assigned for the mesh application.