2021 BILLING AND CODING GUIDE HERNIA & ABDOMINAL WALL ...
2022 Billing and Coding Guide
Hernia & Abdominal Wall Repair Surgery
Rates listed in this guide are based on their respective site of care- physician office, ambulatory surgical center, or hospital outpatient department. All rates provided are for the Medicare unadjusted national average rounded to the nearest whole number for 2022 and do not represent adjustment specific to the provider's location or facility. Commercial rates are based on individual contracts. Providers are encouraged to review contracts to verify their specific contracted allowables. Unless otherwise stated in this document, there are no designated HCPCS1 level II codes assigned for hernia and abdominal wall repair procedures.
CPT? Code2
Description
Physician3
Ambulatory Surgical Center4
Hospital Outpatient4
Component Separation
15734
Muscle, myocutaneous, or fasciocutaneous flap; Trunk Facility Only:$1,540 $1,823
$3,596
Diaphragmic Hernia
39501
Repair, laceration of diaphragm, any approach
39503 39541
Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic
Facility Only:$878 Facility Only: $5,909
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Facility Only: $966
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Enterolysis 44005 Enterolysis (freeing of intestinal adhesion) (separate Facility Only: $1,126
procedure) 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal Facility Only: $949
adhesion) (separate procedure)
Inpatient Procedures, not reimbursed in
outpatient or ASC by Medicare
NA
$5,168
Epigastric Hernia 49570 Repair epigastric hernia (eg, preperitoneal fat);
reducible (separate procedure) 49572 Repair epigastric hernia (eg, preperitoneal fat);
incarcerated or strangulated
Facility Only: $435 $1,440 Facility Only: $538 $1,440
$3,249 $3,249
Femoral Hernia
49550 Repair initial femoral hernia, any age; reducible
49553
Repair initial femoral hernia, any age; incarcerated or strangulated
49555 Repair recurrent femoral hernia; reducible
49557
Repair recurrent femoral hernia; incarcerated or strangulated
Facility Only: $597 Facility Only: $656
Facility Only: $627 Facility Only: $750
$1,440 $1,440
$1,440 $1,440
$3,249 $3,249
$3,249 $3,249
1 |
CPT? Code2
Description
Incisional/Ventral Hernia 49560 Repair initial incisional or ventral hernia; reducible
Physician3
Ambulatory Surgical Center4
Hospital Outpatient4
Facility Only: $763 $1,440
$3,249
49561 Repair initial incisional or ventral hernia; incarcerated or Facility Only: $960 $1,440
strangulated
49565 Repair recurrent incisional or ventral hernia; reducible Facility Only: $794 $2,363
49566 Repair recurrent incisional or ventral hernia; incarcerated Facility Only: $968 $2,363
or strangulated
+495685 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of
Facility Only: $273 NA
debridement for necrotizing soft tissue infection (List
separately in addition to code for the incisional or ventral
hernia repair)
49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian Facility Only: $770 $2,363
or epigastric hernia (includes mesh insertion, when
performed); reducible
49653 Laparoscopy, surgical, repair, ventral, umbilical, spigelian Facility Only: $964 $2,363
or epigastric hernia (includes mesh insertion, when
performed); incarcerated or strangulated
49654 Laparoscopy, surgical, repair, incisional hernia (includes Facility Only: $873 $3,890
mesh insertion, when performed); reducible
49655 Laparoscopy, surgical, repair, incisional hernia (includes Facility Only: $1,070 $3,890
mesh insertion, when performed); incarcerated or
strangulated
49656 Laparoscopy, surgical, repair, recurrent incisional hernia Facility Only: $949 $3,890
(includes mesh insertion, when performed); reducible
49657 Laparoscopy, surgical, repair, recurrent incisional hernia Facility Only: $1,362 $3,890
(includes mesh insertion, when performed); incarcerated
or strangulated
Inguinal Hernia
49492 Repair, initial inguinal hernia, preterm infant (younger
Facility Only: $995 NA
than 37 weeks gestation at birth), performed from birth
up to 50 weeks postconception age, with or without
hydrocelectomy; incarcerated or strangulated
49495 Repair, initial inguinal hernia, full term infant younger
Facility Only: $423 $1,440
than age 6 months, or preterm infant older than 50
weeks postconception age and younger than age 6
months at the time of surgery, with or without
hydrocelectomy; reducible
49496 Repair, initial inguinal hernia, full term infant younger
Facility Only: $638 $1,440
than age 6 months, or preterm infant older than 50
weeks postconception age and younger than age 6
months at the time of surgery, with or without
hydrocelectomy; incarcerated or strangulated
49500 Repair initial inguinal hernia, age 6 months to younger Facility Only: $431 $1,440
than 5 years, with or without hydrocelectomy; reducible
$3,249 $5,168 $5,168 Packaged Service/Item
$5,168 $5,168 $9,096 $9,096 $9,096 $9,096
$3,249
$3,249
$3,249
$3,249
2 |
CPT? Code2
Description
Physician3
Ambulatory Surgical Center4
Hospital Outpatient4
49501
Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; Incarcerated or strangulated
Facility Only: $629 $1,440
49505
Repair initial inguinal hernia, age 5 years or older; reducible
Facility Only:$542 $1,440
49507
Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated
Facility Only:$608 $1,440
49520 Repair recurrent inguinal hernia, any age; reducible
Facility Only: $656 $1,440
49521
Repair recurrent inguinal hernia, any age; incarcerated or Facility Only: $742 $1,440 strangulated
49525 Repair inguinal hernia, sliding, any age
Facility Only: $595 $1,440
49650 Laparoscopy, surgical; repair initial inguinal hernia
Facility Only: $448 $2,363
49651 Laparoscopy, surgical; repair recurrent inguinal hernia Facility Only: $585 $2,363
Lumbar Hernia
49540 Repair lumbar hernia
Facility Only: $700 $2,363
$3,249
$3,249 $3,249 $3,249 $3,249 $3,249 $5,168 $5,168
$5,168
Mesh Implant Hernia +495685 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 the incisional or ventral hernia repair)
Facility Only: $273 Packaged Service/Item
Packaged Service/Item
Paracolostomy Hernia
44346 Revision of colostomy; with repair of paracolostomy
Facility Only:
NA
NA
hernia (separate procedure)
$1,214
Paraoesophageal Hernia 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg,
Nissen, Toupet procedures)
43281 43282 43325
Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh Esophagogastric fundoplasty; with fundic patch (ThalNissen procedure)
43327
Esophagogastric fundoplasty partial or complete; laparotomy
43328
Esophagogastric fundoplasty partial or complete; thoracotomy
43332
Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis
Facility Only: $1,113 Facility Only: $1,586
Facility Only: $1,783
Facility Only: $1,405 Facility Only: $846 Facility Only: $1,146 Facility Only: $1,185
NA
$9,096
NA
$9,096
NA
$9,096
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
3 |
CPT? Code2 43333
43334
43335
43336
43337
Description
Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis
Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis
Physician3
Facility Only: $1,294
Facility Only: $1,270
Facility Only: $1,359
Facility Only: $1,477
Facility Only: $1,574
Ambulatory Surgical Center4
Hospital Outpatient4
Inpatient Procedures, not reimbursed in
outpatient or ASC by Medicare
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Robotic
S2900
Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)
HCPCS II S-Codes cannot be reported to Medicare. They are used only by non-Medicare payers, which coverage and price them according to their own requirements.
Spigelian Hernia
49590 Repair spigelian hernia
Facility Only: $594
$1,440
$3,249
TRAM Flap
19367
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;
Facility Only: $1,811
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
19368
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis
Facility Only: $2,222
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
(supercharging)
19369
Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site
Facility Only: $2,065
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Umbilical Hernia
49580 Repair umbilical hernia, younger than age 5 years; reducible
Facility Only: $350 $1,440
$3,249
49582 Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated
Facility Only: $504 $1,440
$3,249
49585 Repair umbilical hernia, age 5 years or older; reducible
Facility Only: $464 $1,440
$3,249
49587 Repair umbilical hernia, age 5 years or older; incarcerated or reducible
Unlisted Hernia
Facility Only: $496 $1,440
$3,249
49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
Carrier Priced
Not reimbursed in $5,168 ASC by Medicare
4 |
HCPCS Supply Codes
Providers may choose to report a HCPCS level II code to describe the device or supply used for the repair.
HCPCS Code
Description
C1726 C1781 C9364
Catheter, balloon dilatation, non-vascular Mesh (implantable) Porcine implant, permacol, per square centimeter
Hospital Inpatient Procedure Coding
Abdominal Wall Repair In general, abdominal wall repair uses the same coding principles and the same code values as hernia repair. An abdominal wall repair is differentiated from a hernia repair by the ICD-10-CM diagnosis codes, not necessarily by the ICD-10-PCS5 procedure codes. Abdominal wall repair is not coded separately when an associated procedure is performed on an internal organ because procedural steps necessary to close an operative site are considered integral.6
SECTION BODY SYSTEM OPERATION
0 Medical and Surgical W Anatomical Regions, General Q Repair, Restoring, to the extent possible, a body part to its normal anatomic structure and function
Body Part
0 Head 2 Face 4 Upper Jaw 5 Lower Jaw 8 Chest Wall K Upper Back L Lower Back M Perineum, Male N Perineum, Female
6 Neck F Abdominal Wall
6 Neck F Abdominal Wall C Mediastinum
Approach 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External
0 Open 3 Percutaneous 4 Percutaneous Endoscopic
X External 0 Open 3 Percutaneous 4 Percutaneous Endoscopic
Device Z No Device
Z No Device Z No Device Z No Device
Qualifier Z No Qualifier
Z No Qualifier 2 Stoma Z No Qualifier Z No Qualifier
5 |
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