incisional hernia repairs

[butterfly0660]

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Just out of curiosity...does anyone know how much different the reimbursement is for a hernia repair with mesh, versus bilateral component separation? I have one attending who insists on doing bilateral component separation on almost everyone, and I was wondering if it had anything to do with $$$.

 

[XoQo]

Just out of curiosity...does anyone know how much different the reimbursement is for a hernia repair with mesh, versus bilateral component separation? I have one attending who insists on doing bilateral component separation on almost everyone, and I was wondering if it had anything to do with $$$.

http://www.goremedical.com/en/file/AJ0554.pdf

Lists national medicare info for hernia repairs...including CPT code, and reimbursement. I kinda got dizzy reading the tables (they give inpt and outpt tables).

But if you scroll to page 5, you'll see their examples. Based on what i see from this table, the mesh implantation itself does not lead to additional compensation for the surgeon vs a non-mesh repair....even the hospital doens't get paid more for using the device.

Maybe WS might be able to help us make sure we're interpreting this right...i barely even know what a CPT or ICD-9 is heh. 🙁

 

[Castro Viejo]

Just out of curiosity...does anyone know how much different the reimbursement is for a hernia repair with mesh, versus bilateral component separation? I have one attending who insists on doing bilateral component separation on almost everyone, and I was wondering if it had anything to do with $$$.

Well the literature sort of supports component separation as a good way to fix incisional hernias, but most papers show a slightly higher increase in recurrence versus prosthetic mesh repair.

As far as reimbursement is concerned, the CPT code for a ventral/incisional hernia repair is going to be the same whether you utilize a component separation or mesh. The mesh garners another CPT code ("implantation of mesh").

Conceivably there is a slightly higher physician fee with use of mesh in the repair. Without it, whether you go to town with a simple old repair versus a component separation versus the dreaded Stoppa repair, it'll all give you the same amount of cash at the end of the day.

Your attending who insists on a component separation may just be more comfortable with this particular technique and has had better results with it than with anything else. Either that or the patients he's operating on have contraindications to use of a mesh.

One of my attendings, in repairs of inguinal hernias, absolutely refuses to do anything but a Shouldice repair. The rest of the world except for some people in Canada probably use plugs and patches or PHS these days, but he loves that Shouldice and he won't change for anything.

Surgeons are not animals prone to adaptation.

 

[Winged Scapula]

Au contraire my young friends.

You do not just code for the hernia repair.

You can code for the hernia repair, and placement of mesh AND for complex tissue rearrangement (ie, component separation).

The latter is a much higher reimbursement than the hernia repair itself, so if your attending is wise, he codes that first and then adds a Modifier 51 (second procedure) to the hernia repair and mesh placement because most insurance companies will drop reimbursement for the 2nd (and subsequent) procedures by 50%. Insurance companies are supposed to use Medicare guidelines and medicare pays 100% for the first procedure and 50% for subsequent ones. Some insurance companies will use old guidelines which pay 100/50/25, etc. So always code the higher paying one first.

There is a modifier for bilateral procedures, which reduces the reimbursement (ie, he will not get double the reimbursement for 14XXX just because he did it the same day). Obviously, I deal with this a lot given BRCA and other high risk patients who want bilateral mastectomies. Lot of work for me with less reimbursement but its hard to convince them to come back another day to do the other side! 😉 Modifier 50 for bilateral procedures.

For example:

14XXX -50 (I'm not sure of the exact code since these tissue transfers are dependent on cm moved; but I'll bet its the highest coding one since they rarely go above 20 or 30 cm in the codes): reimbursement around $900-$1000 (2008 Medicare rates; YM (and contracts) MV)

49560-51 Repair non-incarcerated incisional hernia: reimbursement around $600-$700 (but you will get 50% or less depending on contract)

49568-51 Placement of Mesh for Incisional hernia repair: reimbursement around $200-$300 (again, with at least 50% reduction)

If you do all 3 (presuming there is a reason to do a tissue transfer AND mesh) or only two, you can see that the component separation garners you more bucks at the end of the day than just a regular repair with or without mesh.

 

[Winged Scapula]

http://www.goremedical.com/en/file/AJ0554.pdf

Lists national medicare info for hernia repairs...including CPT code, and reimbursement. I kinda got dizzy reading the tables (they give inpt and outpt tables).

But if you scroll to page 5, you'll see their examples. Based on what i see from this table, the mesh implantation itself does not lead to additional compensation for the surgeon vs a non-mesh repair....even the hospital doens't get paid more for using the device.

I'm learning too, but here is as I understand it:

Do not confuse what the physician charges with hospital charges. So using the table on page 5:

CPT Code 49561 (incarcerated hernia):

- the physician is reimbursed the same amount of money ($820) whether he does it in a facility (ie, hospital) or non-facility (ie, his office..not that he would do it there)

- if the patient is inpatient, the hospital collects $4599 for this DRG group

- if the patient is outpatient, the hospital collects $1796

- if done in an ASC, the reimbursement is (to the ASC, of which you may be part owner): $1339

Now if you add implanting the mesh (CPT 49568):

- the physician garners another $250 (although as I noted above, it will be discounted as a multiple procedure modifier)

- the hospital gets no more for the procedure because its bundled into the DRG (although they can charge for the mesh itself)

- the outpatient reimbursement to the hospital facility is:$898

- for the ASC its $497. All of which are added to the reimbursement for the procedure.

So it all works out that the physician in PP who owns the ASC gets the most because you can charge professional and facility fees.

The concept of DRGs is why you will often hear from your radiology friends that they won't get paid if they do that CT/MRI etc for a patient who is in-house and could have it done as an outpatient.

 

[Castro Viejo]

Au contraire my young friends.

You do not just code for the hernia repair.

You can code for the hernia repair, and placement of mesh AND for complex tissue rearrangement (ie, component separation).

I love it when attendings talk CPT codes and reimbursements. 🙂

 

[Winged Scapula]

I love it when attendings talk CPT codes and reimbursements. 🙂

Sexy talk ain't it?

When its your livelihood, you'll do it too!😛

 

[Blade28]

Component separation for incisional hernias? 😕 Or a big ventral hernia?

 

[Castro Viejo]

Sexy talk ain't it?

When its your livelihood, you'll do it too!😛

I love it.

 

[Castro Viejo]

Component separation for incisional hernias? 😕 Or a big ventral hernia?

Yes. In either case they're God-awfully long cases.

 

[XoQo]

Now if you add implanting the mesh (CPT 49568):

- the physician garners another $250 (although as I noted above, it will be discounted as a multiple procedure modifier)

- the hospital gets no more for the procedure because its bundled into the DRG (although they can charge for the mesh itself)

- the outpatient reimbursement to the hospital facility is:$898

- for the ASC its $497. All of which are added to the reimbursement for the procedure.

hmm...just to make sure i get this right...

CPT 49568 (+$250) for the physician can only be coded if you do a incisional or ventral hernia repair and implant a mesh.

if you do an inguinal repair, you include the CPT code for use of a mesh plug (CPT C1781) but don't get paid for it.


...now i understand why everybody keeps talking about attending coding workshops....


it's a shame that they don't carve out a little time during med school for this...

 

[Winged Scapula]

hmm...just to make sure i get this right...

CPT 49568 (+$250) for the physician can only be coded if you do a incisional or ventral hernia repair and implant a mesh.

if you do an inguinal repair, you include the CPT code for use of a mesh plug (CPT C1781) but don't get paid for it.


...now i understand why everybody keeps talking about attending coding workshops....


it's a shame that they don't carve out a little time during med school for this...

I think so, but again, I am still learning.

I do not believe there is a code for implanting mesh into an inguinal hernia repair so I believe you get paid the same whether you implant mesh or not.

You never get paid for C codes...these are simply Medicare tracking codes. From the CMS site: "C-codes were reinstated to improve collection of device cost data. Hospitals will continue to be paid for outpatient care using APC rates based on procedures performed but will not receive additional payment based on C- code reporting."

Medical school would not necessarily be the best time to use this because the rules change often and its probably better to learn it when you can start applying that learning rather than learning it by rote memory.

 

[XoQo]

Medical school would not necessarily be the best time to use this because the rules change often and its probably better to learn it when you can start applying that learning rather than learning it by rote memory.

makes sense.

<begin rant>
still...a brief primer (<1 hour) wouldn't hurt one bit. And maybe it could save us another hour from discussion about topics that get beaten to death during 4 years of med school like...abortion, physician assisted suicide, Jehovah's witnesses and blood products.
</end rant>

 

[Winged Scapula]

makes sense.

<begin rant>
still...a brief primer (<1 hour) wouldn't hurt one bit. And maybe it could save us another hour from discussion about topics that get beaten to death during 4 years of med school like...abortion, physician assisted suicide, Jehovah's witnesses and blood products.
</end rant>

I hear ya. I come from a psych background and even for me, the endless discussions of empowering patients, etc. were a bit much.

But medical school is not known for teaching useful stuff, at least not clinically useful stuff and certainly not real world stuff.

 

[droliver]

These hernia repairs should actually be reported with the muscle flap codes. "Separation of components" is reported with the trunk muscle flap code, 15734. Since bilateral muscle elevations are performed, 15734 is used twice.

15734 Right abdominal muscle flap (separation of components)
15734-51 Left abdominal muscle flap (separation of components)

This is in addition to the herniorapphy code and mesh code add ons. In re. to the initial question, this will substancially increase the RVU's (reimbursement) associated with the case. This interpretation is supported by the Plastic Surgery member of the CMS coding committee, but I've heard there can be issues with insurers when the rubber meets the road

 

[DrDawg]

Not to add to an already confusing subject, but can't you also add modifiers based on difficulty of the case? ie extensive LOA?

Three is the limit for CPT codes right? Every thing after that is free? or does it add to RVU (which I don't really understand) and thus worth coding.

 

[droliver]

It's actually 5 codes that can be reimbursed on a slding scale. In practice, many of those get disallowed by insurers.

LOA actually has a seperate code of it's own.

 

[Winged Scapula]

Not to add to an already confusing subject, but can't you also add modifiers based on difficulty of the case? ie extensive LOA?

Three is the limit for CPT codes right? Every thing after that is free? or does it add to RVU (which I don't really understand) and thus worth coding.

There is a modifier for difficult cases; you probably won't get paid and you must make sure you dictate why it was so much harder than usual, so that then when you get denied, submit your OP notes, etc. Frankly, after all that, the increase in reimbursement has probably gone out the window with the administrative costs trying to recoup the $$.

 

[chrisisinnocent]

There is a modifier for difficult cases; you probably won't get paid and you must make sure you dictate why it was so much harder than usual, so that then when you get denied, submit your OP notes, etc. Frankly, after all that, the increase in reimbursement has probably gone out the window with the administrative costs trying to recoup the $$.

And there is also a certain % maximum of cases you can use the modifier on. So the cases have to be difficult compared to the cases you normally do.

 

[DrDawg]

There is a modifier for difficult cases; you probably won't get paid and you must make sure you dictate why it was so much harder than usual, so that then when you get denied, submit your OP notes, etc. Frankly, after all that, the increase in reimbursement has probably gone out the window with the administrative costs trying to recoup the $$.

As residents do a majority of the dictations, I have always been amazed that they don't give us a primer on how to dictate so that they can get paid.