In light of additions and deletions to the surgical CPT codes and descriptions for hernia repair, this Timely Topic demonstrates a simple decision tree for anesthesia providers and billers to identify the appropriate anesthesia CPT billing codes for the new descriptions. The existing anesthesia CPT codes are shown in Table 1. The decision tree at the bottom (Figure 1) may perform a lot of “heavy lifting” for the bottom line of many anesthesia practices, helping to ensure proper payment for our services.
Upper vs. Lower Abdomen
In the past, anesthesia billers would potentially need to know detailed clinical history to appropriately code the procedure. Now, with the new surgical hernia repair CPT coding, the first branch of the anesthesia CPT decision tree is the location of the hernia repair relative to the umbilicus (Figure 1). If the hernia is above the umbilicus, it is considered upper abdominal, and anesthesia CPT codes 00750, 00752, or 00790 are appropriate. If it is below the umbilicus, it is considered lower abdominal, and anesthesia codes 00830, 00832, 00834, 00836, or 00840 are appropriate.
A. Reducibility, Strangulation & Incarceration
In keeping with increased anesthesia work intensity from intraperitoneal procedures, the next step is the hernia’s relationship to the peritoneum. For reducible hernias, an intraperitoneal approach for the hernia repair may or may not be necessary. For incarcerated or strangulated hernias, an intraperitoneal approach is likely to be necessary to ensure that there is no residual bowel ischemia or infarction. Upper abdominal intraperitoneal hernia repairs would use anesthesia CPT code 00752 if the hernia is reducible and 00790 if the hernia is incarcerated or strangulated. For lower abdominal hernia procedures, anesthesia CPT code 00832 is used if the hernia is reducible and 00840 if it is incarcerated or strangulated.
Although the surgical descriptors no longer include epigastric, incisional, ventral, and Spigelian, the new surgical codes allow for the increased challenges associated with hernia repairs in unusual locations (e.g. lumbar triangle hernias), incisional hernias (where there may be scar tissue), or dehiscence. These conditions and others can increase the requirements and intensity of the required anesthetic management and are captured with the complex repair code of 00752 for upper abdominal and 00832 for lower abdominal hernias.
C. Patient’s Age
Special consideration for patient age at the time of repair is made due to the added complexity and anesthesia work intensity. In lower abdominal hernia repairs on children under one year of age, the anesthesia CPT code used is 00834. Further, if the patient has a lower abdominal hernia repair AND is born prematurely at less than 37 weeks of gestation and is less than 50 weeks of gestational age at the time of surgery, the anesthesia CPT code is 00836. Existing anesthesia codes for the complex upper abdominal wall defects of omphalocele and gastroschisis are separate from the hernia codes.
Some examples are listed in Table 2 for demonstration.
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Table 1: Summary of Anesthesia for Hernia Repair CPT Codes
||Anesthesia for hernia repairs in upper abdomen; NOS
||Anesthesia for hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound dehiscence
||Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; NOS
||Anesthesia for hernia repairs in lower abdomen; NOS
||Anesthesia for hernia repairs in lower abdomen; ventral and incisional hernias
||Anesthesia for hernia repairs in the lower abdomen not otherwise specified; younger than 1 year of age
||Anesthesia for hernia repairs in the lower abdomen not otherwise specified, infants younger than 37 weeks gestational age at birth and younger than 50 weeks gestational age at time of surgery
||Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; NOS
Figure 1: Decision Tree
* For children under age 1 yr, use 00834
If <37 week prematurity at birth AND <50 weeks gestation at surgery, use 00836
Table 2. Examples of Anesthesia Billing Based on New Hernia CPT Code Descriptions
|Previous Surgical Descriptions
|| CPT CODES
| BASE UNITS
||New Surgical descriptions (alternate)
|36 y.o. reducible, initial inguinal hernia
||Lower abdominal, simple
|4 y.o. reducible, umbilical hernia
||Upper abdominal, reducible, complex
|20 y.o. incarcerated, initial parastomal hernia
||Lower abdominal, incarcerated
|42 y.o. strangulated, recurrent ventral hernia
||Upper abdominal, strangulated, complex
|40 wk gestational 35wk Premie incarcerated inguinal hernia
||Lower abdominal, simple or complex