Hernia RepairCoverage, Coding and Reimbursement Overview — Hospital Outpatient/ASC2019 Edition — All Reimbursement Amounts are Listed at National Unadjusted Medicare Rates and Do Not Include the 2% Sequestration Reduction

Hospital Outpatient rates effective January 1, 2019 through December 31, 2019

PROCEDUREA CODINGHCPCS/CPT®

CodeA APC SIB RateC

C1781 ---- N ----Procedure (Non-Inguinal)DIAPHRAGMATIC REPAIRRepair, neonatal diaphragmatic hernia, with or without chest tube insertion 39503 ---- C ---- and with or without creation of ventral hernia

Repair, diaphragmatic hernia (other than neonatal), traumatic; acute 39540 ---- C ----

chronic 39541 ---- C ----EPIGASTRIC HERNIA REPAIRRepair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) 49570 5341 J1 $2,947

incarcerated or strangulated 49572 5341 J1 $2,947FEMORAL HERNIA REPAIRRepair initial femoral hernia, any age; reducible 49550 5341 J1 $2,947

incarcerated or strangulated 49553 5341 J1 $2,947

Repair recurrent femoral hernia; reducible 49555 5341 J1 $2,947

incarcerated or strangulated 49557 5341 J1 $2,947INCISIONAL/VENTRAL HERNIA REPAIRRepair initial incisional or ventral hernia; reducible 49560 5341 J1 $2,947

incarcerated or strangulated 49561 5341 J1 $2,947

Repair recurrent incisional or ventral hernia; reducible 49565 5361 J1 $4,596

incarcerated or strangulated 49566 5361 J1 $4,596

Implantation of mesh or other prosthesis for open incisional or ventral hernia +49568 ---- N ----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)

A. Listed are common procedures. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. Current Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.B. Status Indicators: C-Inpatient Procedure; J1-Hospital Part B Services Paid Through a Comprehensive APC; N-ltems and Services Packaged into APC Rates. C. Rates are from CY 2019 Hospital Outpatient Prospective Payment System Final Rule, CMS-1695-CN2, Centers for Medicare and Medicaid Services.

*Per CMS-1695-FC, device-intensive procedures require the reporting of a device HCPCS code. Device code reporting requirements apply.

REIMBURSEMENTB

Device Code*Mesh, Implantable

HOSPITAL OUTPATIENT REVIEW

Hospital Outpatient rates effective January 1, 2019 through December 31, 2019

PROCEDUREA CODINGHCPCS/CPT®

CodeA APC SIB RateC

Procedure (Non-Inguinal)LAPAROSCOPIC HERNIA REPAIRLaparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 43281 5362 J1 $7,742when performed; without implantation of mesh

with implantation of mesh 43282 5362 J1 $7,742

Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis +43283 ---- C ----gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)

Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia 49652 5361 J1 $4,596(includes mesh insertion, when performed); reducible

incarcerated or strangulated 49653 5361 J1 $4,596

Laparoscopy, surgical, repair, incisional hernia (includes mesh 49654 5362 J1 $7,742insertion, when performed); reducible

incarcerated or strangulated 49655 5362 J1 $7,742

Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh 49656 5362 J1 $7,742insertion, when performed); reducible

incarcerated or strangulated 49657 5362 J1 $7,742

Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy 49659 5361 J1 $4,596LUMBAR HERNIA REPAIRRepair lumbar hernia 49540 5361 J1 $4,596OMPHALOCELE HERNIA REPAIRRepair of small omphalocele, with primary closure 49600 5341 J1 $2,947

Repair of large omphalocele or gastroschisis; with or without prosthesis 49605 ---- C ----

with removal of prosthesis, final reduction and closure, in operating room 49606 ---- C ----

Repair of omphalocele (Gross type operation); first stage 49610 ---- C ----

second stage 49611 ---- C ----

A. Listed are common procedures. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. Current Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.B. Status Indicators: C-Inpatient Procedure; J1-Hospital Part B Services Paid Through a Comprehensive APC.C. Rates are from CY 2019 Hospital Outpatient Prospective Payment System Final Rule, CMS-1695-CN2, Centers for Medicare and Medicaid Services.

REIMBURSEMENTB

HOSPITAL OUTPATIENT REVIEW

Hospital Outpatient rates effective January 1, 2019 through December 31, 2019

PROCEDUREA CODINGHCPCS/CPT®

CodeA APC SIB RateC

Procedure (Non-Inguinal)PARAESOPHAGEAL HERNIA REPAIRRepair, paraesophageal hiatal hernia (including fundoplication), via 43332 ---- C ----laparotomy, except neonatal; without implantation of mesh or other prosthesis

with implantation of mesh or other prosthesis 43333 ---- C ----

Repair, paraesophageal hiatal hernia (including fundoplication), via 43334 ---- C ----thoracotomy, except neonatal; without implantation of mesh or other prosthesis

with implantation of mesh or other prosthesis 43335 ---- C ----

Repair, paraesophageal hiatal hernia, (including fundoplication), via 43336 ---- C ----thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis

with implantation of mesh or other prosthesis 43337 ---- C ----

Esophageal lengthening procedure (eg, Collis gastroplasty or wedge +43338 ---- C ----gastroplasty) (List separately in addition to code for primary procedure)SPIGELIAN HERNIA REPAIRRepair spigelian hernia 49590 5341 J1 $2,947UMBILICAL HERNIA REPAIRRepair umbilical hernia, younger than age 5 years; reducible 49580 5341 J1 $2,947

incarcerated or strangulated 49582 5341 J1 $2,947

Repair umbilical hernia, age 5 years or older; reducible 49585 5341 J1 $2,947

incarcerated or strangulated 49587 5341 J1 $2,947

A. Listed are common procedures. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. Current Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.B. Status Indicators: C-Inpatient Procedure; J1-Hospital Part B Services Paid Through a Comprehensive APC. C. Rates are from CY 2019 Hospital Outpatient Prospective Payment System Final Rule, CMS-1695-CN2, Centers for Medicare and Medicaid Services.

REIMBURSEMENTB

HOSPITAL OUTPATIENT REVIEW

ASC rates effective January 1, 2019 through December 31, 2019

PROCEDUREA CODINGHCPCS/CPT®

CodeA Rate

Procedure (Non-Inguinal)DIAPHRAGMATIC REPAIRRepair, neonatal diaphragmatic hernia, with or without chest tube insertion 39503and with or without creation of ventral hernia

Repair, diaphragmatic hernia (other than neonatal), traumatic; acute 39540

chronic 39541EPIGASTRIC HERNIA REPAIRRepair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) 49570 $1,343

incarcerated or strangulated 49572 $1,343FEMORAL HERNIA REPAIRRepair initial femoral hernia, any age; reducible 49550 $1,343

incarcerated or strangulated 49553 $1,343

Repair recurrent femoral hernia; reducible 49555 $1,343

incarcerated or strangulated 49557 $1,343INCISIONAL/VENTRAL HERNIA REPAIRRepair initial incisional or ventral hernia; reducible 49560 $1,343

incarcerated or strangulated 49561 $1,343

Repair recurrent incisional or ventral hernia; reducible 49565 $2,130

incarcerated or strangulated 49566 $2,130

Implantation of mesh or other prosthesis for open incisional or ventral hernia +49568 Packagedrepair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair)

A. Listed are common procedures. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. Current Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.B. Rates are from the CY 2019 Ambulatory Surgical Payment System Final Rule, CMS-1695-F, Centers for Medicare and Medicaid Services.

REIMBURSEMENTB

Non-Covered

Non-Covered

Non-Covered

AMBULATORY SURGERY CENTER (ASC)

ASC rates effective January 1, 2019 through December 31, 2019

PROCEDUREA CODINGHCPCS/CPT®

CodeA Rate

Procedure (Non-Inguinal)LAPAROSCOPIC HERNIA REPAIRLaparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, 43281when performed; without implantation of mesh

with implantation of mesh 43282

Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis +43283gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)

Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia 49652 $2,130(includes mesh insertion, when performed); reducible

incarcerated or strangulated 49653 $2,130

Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when 49654 $3,428performed); reducible

incarcerated or strangulated 49655 $3,428

Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh 49656 $3,428insertion, when performed); reducible

incarcerated or strangulated 49657 $3,428

Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy 49659LUMBAR HERNIA REPAIRRepair lumbar hernia 49540 $2,130OMPHALOCELE HERNIA REPAIRRepair of small omphalocele, with primary closure 49600 $1,343

Repair of large omphalocele or gastroschisis; with or without prosthesis 49605

with removal of prosthesis, final reduction and closure, in operating room 49606

Repair of omphalocele (Gross type operation); first stage 49610

second stage 49611

A. Listed are common procedures. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. Current Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.B. Rates are from the CY 2019 Ambulatory Surgical Center Payment Final Rule, CMS-1695-CN2, Centers for Medicare and Medicaid Services.

Non-Covered

Non-Covered

Non-Covered

Non-Covered

Non-Covered

Non-Covered

Non-Covered

Non-Covered

REIMBURSEMENTB

AMBULATORY SURGERY CENTER (ASC)

ASC rates effective January 1, 2019 through December 31, 2019

PROCEDUREA CODINGHCPCS/CPT®

CodeA Rate

Procedure (Non-Inguinal)PARAESOPHAGEAL HERNIA REPAIRRepair, paraesophageal hiatal hernia (including fundoplication), via 43332laparotomy, except neonatal; without implantation of mesh or other prosthesis

with implantation of mesh or other prosthesis 43333

Repair, paraesophageal hiatal hernia (including fundoplication), via 43334thoracotomy, except neonatal; without implantation of mesh orother prosthesis

with implantation of mesh or other prosthesis 43335

Repair, paraesophageal hiatal hernia, (including fundoplication), via 43336thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis

with implantation of mesh or other prosthesis 43337

Esophageal lengthening procedure (eg, Collis gastroplasty or wedge +43338gastroplasty) (List separately in addition to code for primary procedure)SPIGELIAN HERNIA REPAIRRepair spigelian hernia 49590 $1,343 UMBILICAL HERNIA REPAIRRepair umbilical hernia, younger than age 5 years; reducible 49580 $1,343

incarcerated or strangulated 49582 $1,343

Repair umbilical hernia, age 5 years or older; reducible 49585 $1,343

incarcerated or strangulated 49587 $1,343

A. Listed are common procedures. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. Current Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.B. Rates are from the CY 2019 Ambulatory Surgical Center Payment Final Rule, CMS-1695-CN2, Centers for Medicare and Medicaid Services.

Non-Covered

Non-Covered

Non-Covered

Non-Covered

Non-Covered

Non-Covered

REIMBURSEMENTB

Non-Covered

AMBULATORY SURGERY CENTER (ASC)