Hernia Repair Coding in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
May 18th, 2023

In the 2023, Current Procedural Terminology (CPT) updates, the American Medical Association (AMA) stated the Relative Value Scale Update Committee (RUC) performed a review of codes with a “site-of-service” anomaly. This means they reviewed codes with a global period that included inpatient Evaluation and Management (E/M) service codes in their database even though more than 50% of the claims containing these codes were actually performed on an outpatient basis. As part of the outcome of this review, several procedures were identified, analyzed, and revised, which resulted in the deletion of a number of codes, several revisions, and of course the addition of new procedure codes. Many of you recall seeing a large revision of the hernia repair procedure codes announced, but few realize the significance of these revisions. According to the 2023 published CPT changes, the following hernia repair codes were deleted: 

Open Hernia Repair Codes Deleted in 2023

The following open hernia repair codes were deleted in 2023:

• Repair initial incisional or ventral hernia;
  • 49560 (reducible)
  • 49561 (incarcerated or strangulated)
• Repair recurrent incisional or ventral hernia; 
  • 49565 (reducible)
  • 49566 (incarcerated or strangulated)
• Repair epigastric hernia (e.g., preperitoneal fat); 
  • 49570 (reducible)
  • 49572 (incarcerated or strangulated)
• Repair umbilical hernia, younger than age 5 years; 
  • 49580 (reducible)
  • 49582 (incarcerated or strangulated)
• Repair umbilical hernia, age 5 years or older; 
  • 49587 (reducible)
  • 49587 (incarcerated or strangulated)
• Repair spigelian hernia 49590
• Add-on code (+)
  • 49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for incisional or ventral hernia repair). 

Laparoscopic Hernia Repair Codes Deleted in 2023

The following laparoscopic hernia repair codes were deleted in 2023:

• Laparoscopy, surgical repair with mesh insertion, when performed
  • ventral, umbilical, spigelian, or epigastric hernia; 
    • 49652 reducible
    • 49653 incarcerated or strangulated
  • incisional hernia with mesh insertion, when performed; 
    • 49654 reducible
    • 49655 incarcerated or strangulated
  • recurrent incisional hernia; 
    • 49656 reducible
    • 49657 incarcerated or strangulated

New ZERO-Day Global Period Anterior Abdominal Hernia Repair Codes

The following anterior abdominal hernia repair codes were added in January 1, 2023 with special rules and guidelines for measuring, approach, and reporting single or multiple hernia repairs: 

While non-anterior and anterior abdominal hernia repairs may be reported together, any repairs that have a 90-day global period will also apply to those with a ZERO-day global period and coders will not be able to separately report suture/staple removals or Evaluation and Management (E/M) services separately during that 90-day period. 

For reporting purposes, first determine the total length of the hernia and if multiple, follow the specific directions for measuring multiple hernias. Choose the type of hernia (initial or recurrent), and then finally determine the severity (reducible or incarcerated or strangulated). Identify if there is a higher severity with one hernia versus the others and if there is, code to the highest severity of any defects. Remember that all measurements should be taken before opening the defect to ensure correct coding.

Clinical Documentation Improvement Strategies

To ensure the details are all documented well, be sure to touch base with provider groups and/or supply them either with some one-on-one or group coding updates, cheatsheets, or tips for hitting the key points in the documentation.  

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.