Hernias variables( reducible, incarcerated or strangulated)

Discussion in 'Medical Coding & Reimbursement Discussion' started by Carmen, Sep 27, 2012.

  1. Carmen

    Carmen Carmen Butler, CPC

    Hi Alicia/Laureen,

    How can I determine when is the Hernia Reducible, Incarcerated or Strangulated

    The following scenario is one that has created difficulty for me.

    The patient was brought to the operating roon and placed under general anesthesia, prepped and draped sterilely. An infra-umbilical skin incision was made with a 15 blade and carried down through the subcutaneous tissues using sharp dissection. We carried the dissection down to the fascia and then dissected the umbilicus free from its fascial attachment. We opened the hernia sac, reduced the hernia contents and then repaired the facial defect with interrupted 1-0 Vicril sutures. The ubilicus was tacked back down to the fascia with a single interrupted 3-0 undyed Vicryl. The skin was closed, sponge and needle counts were correct. Patient tolerated the procedure well.


    My choice 49585
    The correct choice 49587
     
  2. Karen Fan

    Karen Fan New Member

    Hi Carmen,

    When I first looked at the scenario I thought the same thing. However when I looked at the difference between the words in the medical dictionary, I found that reducible means restoration to normal position, strangulation is the entrapment of the intestine in a hernia which leads to vascular compromise with ensuing gangrene. Since the contents were reduced instead of just put back into place. This is the difference and why the answer is 49587.

    Karen
     
  3. Carmen

    Carmen Carmen Butler, CPC

    Hi Karen,
    Thank you for your help, I am still confused.....Was this a reduced hernia? Because the codes are as follow;

    49585- Repair of Umbilical hernia, age 5 years or older; reducible

    49587- Repair of Umbilical hernia, age 5 years or older; incarcerated or strangulated.

    By reading the scenario my conclusion was reducible hernia (49585) because the cuote "We opened the hernia sac, reduced the hernia contents and them repaired the fascial defect" no word of being incarcerated or strangulated. I think I am missing something.

    Thanks again!
     
  4. Karen Fan

    Karen Fan New Member

    Hi Carmen,
    We opened the hernia sac, reduced the hernia contents and then repaired the facial defect with interrupted 1-0 Vicril sutures. The ubilicus was tacked back down, In the scenario they state that the contents were reduced, what this means is that they removed the contents from the sac then sewed it closed. This is not the same meaning as the code 49585, that code only means to pick up the herniated sac and move it back into place. Since the doctor had to repair the defect that falls into a strangulated hernia code 49587.

    Thanks Karen
     
  5. Carmen

    Carmen Carmen Butler, CPC

    Karen,

    You are just amazing.....I get it now...woowoo....

    Thanks, Carmen
     
  6. Karen Fan

    Karen Fan New Member

    Hi Carmen,

    You don't know how much I needed to hear that. Very glad I could help.


    Thanks Karen
     
  7. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    Just wanted to add my 2 cents.

    Reducible means restoring to normal state. You can reduce a fracture (ever heard of a doctor re-braking a patients nose once it was fractured?) - you can reduce a hernia i.e.. pop it back into place. Then they normally put mesh over the weakened area to prevent it from happening again.

    In your report they said they reduced it - good documentation - so it is the 49585 code.

    Check out this great website for hernia info http://www.hernianetwork.com/facts.php
     
  8. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    Here's another great video

     
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  9. Luna

    Luna Active Member

    This is all very interesting.

    I'm not a coder by any means yet. However, looking at the info presented by both Karen and Laureen I have a few thoughts myself. (I can see this is going to be a very challenging career. Good thing I like challenges and love to review and extract data.)

    Anyway, looking at the Website provided by Laureen ( http://www.hernianetwork.com/facts.php ) and the description of the procedures given in Carmen's example I do believe that code 49587 is correct.

    Why: The procedure involved more than just reducing (putting back) the hernia. The procedure involved reducing the "hernia contents". This indicates that the hernia was strangulated or contained gangrene and necrotic bowel.

    Not sure Carmen if this was a test/quiz/workbook question, but I bet the wording was carefully chosen so as to make you think a little deeper about what all the procedure involved. Just putting the hernia back "reduces" the hernia, yes. However, it also involved reducing the "hernia contents" which I think would be code 49587.

    I will admit that I am only......80% confident because I have no coding experience at all! I have yet to see a manual. I will be starting my MTA/PBC courses next week and am very excited about it.
     
    Carmen likes this.
  10. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    I think part of the problem here is understanding when they say "reducible" in the code description they mean manually or without need of surgery. Then in the op report they use terms like "reduce" and that makes us think "oh it's a reducible" hernia which it does not. I feel for this myself.

    Here is another source defining this:
    Reducible vs Nonreducible Hernias

    A hernia with a bulge can be classified based on whether or not the bulge can be flattened.

    • A reducible hernia is a hernia with a bulge that flattens out when you lie down or push against it gently. This type of hernia is not an immediate danger to a person’s health, although it may be painful and worsen over time if left untreated.
    • A nonreducible hernia occurs when the loop of the intestine becomes trapped and a person loses the ability to make the bulge flatten out. Nonreducible hernias are often very painful and require prompt medical attention.
    From http://www.herniasolutions.com/about-hernias/types-of-hernias#reducible
     
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  11. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    And from CPC Assistant 1994:

     
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  12. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    So you can surgically reduce a hernia (i.e.. put the contents back where they belong) but that doesn't mean it was diagnostically considered a reducible hernia (i.e.. able to with your hands push the contents back into place).

    Soooooo we have to look for language that indicates if the contents of the hernia were stuck somehow (incarcerated). This blip is very vague. When I'm reading it I'm not getting the sense anything was trapped. But I don't code these everyday. I'd like to see a "Indications" section of the report to decide. Where did this blurb come from? A practice exam?

    We need to find an experienced hernia coder for this one to be absolutely sure.
     
    Luna likes this.
  13. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    Karen - is this based on some guidelines we could look at? I've been scouring the 'net for hours on this one and it has me a bit unsure. I read "repaired the facial defect" and that doesn't translate to incarcerated contents to me. Just trying to work this out to a definitive conclusion or else it is going to keep bugging me ;-)
     
  14. joannesheehan

    joannesheehan Member CCO Support Staff

    The argument is whether it is reducible or incarcerated or strangulated....
    Key word is reduced.
    Incision was made and hernia was reduced. Notes did not indicate any type of strangulation or incarceration. I would code 49585.
    I came to that conclusion after reading procedure- I double checked with my husband who is also a CPC and a doctor. He said it was 49585 as well.
    I would be interested to see how the correct answer is supposed to be 49587?
    Jo-Anne Sheehan, CPC, CPC-I
     
  15. Luna

    Luna Active Member

    Bear with me. I am mostly making my comment here as a record of what I have learned today- to help it stick in my memory. :)

    I'm not sure if I'm focusing too much on the word reduced or on the word contents (what actually was reduced). Because it does not say "hernia was reduced" as quoted in johnnesheehan's comment. It says "we opened the hernia sac" and "reduced the hernia contents".

    Like Laureen, I spent several hours pouring over internet info (as I don't have any manuals and study books yet) and have maybe been cleared up on a few misconceptions I had.

    When I first read the notes, I pictured them "opening the hernia sac" as meaning they had to literally open the intestine and "reduce the hernia contents" as being they emptied trapped contents from it. However, now I am seeing a different picture. :oops:

    (This has been an excellent research assignment for me.....getting to see how the courses I'll begin taking are going to help me learn how to understand terminology and anatomy.)

    I learned that the "hernia sac" was not the trapped portion of the intestine. It is the peritoneal pouch enclosing the hernia. That is what got opened. "Reduced the hernia contents" must mean simply that they "put back" possibly by manipulation, what the hernia contained (intestine/organs).

    Thus the hernia was reducible.

    Is that my final answer? I think I'll use a life line.
     
  16. Luna

    Luna Active Member

    Definitely need a life line.

    Because...what am I missing? I still have thoughts bouncing between reducible and incarcerated. It was not strangulated or a resection of some kind would be included in the notes would it not? However, incarcerated and strangulated apparently share the same code? But where's the key that indicates that this was incarcerated and thus necessary surgery vs. a reducible hernia where they opted for a repair to keep it from becoming incarcerated or strangulated....?

    I think I'll quit trying to think out loud too much and just "listen" in here for while. What is that saying: It is better to remain silent and be thought a fool than to open one's mouth and remove all doubt. - Abraham Lincoln Well, too late for that now. :(
     
  17. Carmen

    Carmen Carmen Butler, CPC

    Good morning ladies,
    Thank you so much for looking into this question that took so much time and energy for me to understand. This is a question from the Carol Buck's book and the correct answer is 49587. I was confused by the used of the word "reduced" and took me a little time to understand Karen's explanation. Karen explained as follows:

    "We opened the hernia sac, reduced the hernia contents and then repaired the facial defect with interrupted 1-0 Vicril sutures. The ubilicus was tacked back down, In the scenario they state that the contents were reduced, what this means is that they removed the contents from the sac then sewed it closed. This is not the same meaning as the code 49585, that code only means to pick up the herniated sac and move it back into place. Since the doctor had to repair the defect that falls into a strangulated hernia code 49587".
    Karen Fan.

    These are the challenges to code without the disharge summary.
    I want to thank you all for your input, it has been very educating. And of course the videos are great. Thank you Laureen.
    And Luna, I am impress by you...

    Carmen
     
  18. Carmen

    Carmen Carmen Butler, CPC

    This is the entire scenario from chapter 23
    Preoperative Diagnosis: Umbilical hernia
    Postoperative Diagnosis: Same
    Procedure: Umbilical herniorrhaphy
    Anesthesia: General
    Indications: Mrs. Wilson is a 33-year-old female who works at the local college and has noticed increasing periumbilical pain. She has a noticeable bulge that has increased in size over the past several weeks. She denies any symptoms of obstruction. She presents today for elective repair. She understands the risks of bleeding, infection, or possible recurrence and wishes to proceed.
    Procedure: The patient was brought to the operating room and placed under general anesthesia, prepped and draped sterilely. An infra-umbilical skin incision was made with a #15 blade and carried down through the subcutaneous tissues using sharp dissection. We carried the dissection down to the fascia and then dissected the umbilicus free from its fascial attachment. We opened the hernia sac, reduced the hernia contents and then repaired the fascial defect with interrupted 1-0 Vicryl sutures. The umbilicus was tacked back down to the fascia with a single interrupted 3-0 undyed Vicryl. The skin was closed with subcuticular 4-0 undyed Vicryl. Steri-Strips and sterile Band-Aids were applied. Sponge and needle counts were correct prior to leaving the operating room. The wound was anesthetized with 30 ml of 1/2% Sensorcaine with epinephrine solution.
    (Pathology Report) Do not code the pathology report.
    Pathology Report Later Indicated: Tissue showed no evidence of carcinoma.

    [​IMG]
     
  19. Karen Fan

    Karen Fan New Member

    The reason that I agreed with the answer 49587, The umbilicus was dissected free, and the hernia sac was opened the contents were reduced then repaired the fascial defect. This does not seem like a manual reducible hernia to me. In Tabers medical dictionary a reducible hernia is manipulated into place, this procedure is surgical and not just pushed into place with the hands, as stated in wiki medi. I tried to also verify this on Surgeons.net but that only stated how to perform the procedure.

    Karen
     
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  20. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator CCO Support Staff

    Ok I found a coding expert on this topic and she was gracious enough to provide the following. The bottom line is the answer key for this one is wrong.

     
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