How To Use CPT Code 49496

CPT 49496 describes the repair of an initial inguinal hernia in infants under six months of age, either full term or preterm. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49496?

CPT 49496 can be used to describe the repair of an initial inguinal hernia in infants under six months of age. This code is specifically for infants who were born full term or preterm but are older than 50 weeks postconception age at the time of surgery. The procedure may also include the excision of a hydrocele, which is a swelling in the scrotum.

2. Official Description

The official description of CPT code 49496 is: ‘Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated.’

3. Procedure

1. The provider begins by making an incision in the groin area where the hernia is located.
2. They then expose the inguinal canal, which is the passageway in the abdominal wall that contains the spermatic cord in males.
3. The hernia sac is identified and all its contents are removed.
4. If a hydrocele is present, it is incised and the fluid is drained from the scrotal sac.
5. The provider then pushes the hernia back to the level of the fascial defect and repairs the hernia defect using absorbable sutures.
6. The inguinal canal is reconstructed, and the provider checks for bleeding before closing the incision.

4. Qualifying circumstances

CPT 49496 is used for the repair of an initial inguinal hernia in infants under six months of age. The hernia must be incarcerated or strangulated, and the procedure may also include the excision of a hydrocele. It is important to note that this code is specifically for infants who were born full term or preterm but are older than 50 weeks postconception age at the time of surgery.

5. When to use CPT code 49496

CPT code 49496 should be used when performing the repair of an initial inguinal hernia in infants under six months of age. It is important to ensure that the patient meets the specific criteria outlined in the official description, including being either a full term infant younger than age 6 months or a preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery. This code should not be used for hernia repairs on infants age 6 months to younger than 5 years, as there are separate codes for those age groups.

6. Documentation requirements

To support a claim for CPT 49496, the provider must document the following information:

• Patient’s age and gestational age at birth
• Confirmation of an initial inguinal hernia
• Presence of incarceration or strangulation
• Documentation of any hydrocele and its excision, if applicable
• Description of the procedure performed, including the repair of the hernia defect and reconstruction of the inguinal canal
• Confirmation of any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 49496, ensure that the patient meets the specific criteria outlined in the official description. This code should not be reported with modifier 63 or in conjunction with CPT codes 49495 or other similar codes. For bilateral procedures, use modifier 50. It is important to follow the guidelines provided by the payer and ensure accurate documentation to support the claim.

8. Historical information

CPT 49496 was added to the Current Procedural Terminology system on January 1, 1994. There have been several code changes and updates since its addition, including changes to the age criteria and the inclusion of hydrocelectomy.

9. Examples

1. A provider performs the repair of an initial inguinal hernia in a full term infant who is four months old. The hernia is incarcerated, and no hydrocele is present.
2. An infant who was born preterm at 32 weeks gestation undergoes the repair of an initial inguinal hernia at 10 weeks postconception age. The hernia is strangulated, and a hydrocele is also excised during the procedure.
3. A provider performs the repair of an initial inguinal hernia in a full term infant who is three months old. The hernia is incarcerated, and no hydrocele is present.
4. An infant who was born preterm at 35 weeks gestation undergoes the repair of an initial inguinal hernia at 12 weeks postconception age. The hernia is strangulated, and a hydrocele is also excised during the procedure.
5. A provider performs the repair of an initial inguinal hernia in a full term infant who is five months old. The hernia is incarcerated, and no hydrocele is present.
6. An infant who was born preterm at 30 weeks gestation undergoes the repair of an initial inguinal hernia at 11 weeks postconception age. The hernia is strangulated, and a hydrocele is also excised during the procedure.