Overview
This lecture demonstrates start-to-finish examples of coding two surgical cases: a right inguinal hernia repair and a bilateral reduction mammoplasty. It covers diagnosis and procedure code selection using clinical documentation.
Right Inguinal Hernia Repair Coding
- Pre- and post-operative diagnosis: direct right inguinal hernia.
- Procedure: Marlix repair of right inguinal hernia using open technique, spinal anesthesia.
- Preparation and closure steps are typically not separately coded.
- Mesh placement (Marlix patch) is included in the hernia repair code for inguinal hernias (not separately billable).
- Patient age (50 years) can affect code selection for hernia repairs.
- Correct ICD-10-CM code: K40.90 (Unilateral inguinal hernia without obstruction or gangrene, not specified as recurrent).
- Correct CPT code: 49505 (Initial inguinal hernia repair, age 5 years or older, reducible).
Bilateral Reduction Mammoplasty Coding
- Pre- and post-operative diagnosis: bilateral macromastia (enlarged breasts); findings include breast ptosis, back pain, and shoulder pain.
- Documentation must support "bilateral" procedure throughout the operative note.
- Medical necessity is established with symptoms (back and shoulder pain), not just breast size.
- Operative steps: markings, tissue excision, nipple transposition, symmetry check, tissue/skin removal, suction lipectomy (contouring), closure.
- Suction lipectomy for contouring is typically included in the mammoplasty procedure, not separately billable.
- Amount of tissue removed (grams) is documented for insurance purposes.
- Correct ICD-10-CM diagnosis codes:
- N62 (Hypertrophy of breast/macromastia)
- M54.9 (Back pain, unspecified)
- M25.519 (Shoulder pain, unspecified)
- N64.81 (Ptosis of breast)
- Correct CPT code: 19318-50 (Reduction mammoplasty, bilateral; modifier 50 indicates bilateral procedure).
Key Terms & Definitions
- ICD-10-CM — International Classification of Diseases, 10th Revision, Clinical Modification (diagnosis code set).
- CPT — Current Procedural Terminology (procedure code set).
- Modifier 50 — Indicates a bilateral procedure.
- Ptosis — Drooping or sagging of a body part, here referring to breasts.
- Macromastia — Excessively large breasts.
- Mesh — Synthetic material used for tissue reinforcement, often included in hernia repair coding.
Action Items / Next Steps
- Practice coding similar surgical cases using sample operative notes.
- Review CPT and ICD-10-CM guidelines for hernia and breast procedures, including use of modifiers.
- Ensure documentation supports all coded diagnoses and procedures.