Umbilical Hernia Repair CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

Umbilical hernia repair CPT code(s) 49580-49587 reports for service when the physician performs surgery to repair an umbilical (belly button) hernia, whether reducible, incarcerated, or strangulated for under five years or five years.

The physician performs surgery to repair the belly button hernia and make an umbilical incision. They identify the hernia sac and fascial defect and excise it from the surrounding area. 

Umbilical hernia may occur due to the weakness of abdominal muscles, and Incardinated hernia may cause sharp pain, vomiting, nausea, and need emergency medical care. The physician may reduce the defected part or resect that area. Afterward, sutures apply to close the incision.

The following are the reasons why physicians perform Umbilical hernia repair:

Hernia is strangulated causing pain

Size is more than a half-inch 

A hernia may not heal in infants under the five years of age restricts blood flow

May require due to prior surgery

Chronic peritoneal dialysis

Umbilical Hernia Repair CPT Code Description

Umbilical hernia repair CPT code 49580 reports for service when the physician performs surgery to repair an umbilical (belly button) reducible hernia, less than five years of age. 

Umbilical hernia repair CPT code 49585 reports for service when the physician performs surgery to repair an umbilical (belly button) reducible hernia, five years of age or beyond. 

Umbilical hernia repair CPT code 49582 reports for service when the physician performs surgery to repair an umbilical (belly button) incarcerated or strangulated hernia, less than five years of age. 

Umbilical hernia repair CPT code 49587 reports for service when the physician performs surgery to repair an umbilical (belly button) incarcerated or strangulated hernia, five years of age or beyond.

Umbilical Hernia Repair CPT Code Reimbursement

A maximum of one unit can be a bill on the same service date of Umbilical hernia repair CPT code(s) 49580-49587. In contrast, the two-unit allows when documentation supports the medical necessity of the service. 

The cost and RUVS of CPT 49580 are $375.39 and 10.84758 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 49580 are $375.39 and 10.84758 when performed in the non-facility. 

The cost and RUVS of umbilical hernia repair CPT code 49582 are $534.93 and 15.45766 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 49580 are $534.93 and 15.45766 when performed in the non-facility.

The cost and RUVS of CPT 49585 are $492.88 and 14.24266 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 49580 are $492.88 and 14.24266 when performed in the non-facility.

The cost and RUVS of umbilical hernia repair CPT code 49587 are $526.14 and 15.20370 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 49580 are $526.14 and 15.20370 when performed in the non-facility.

Umbilical Hernia Repair CPT Code Billing Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

The payable Dx codes with CPT code 49580-49587 are K42.0, K42.1, and K42.9. 

Hernia repairs define in the following ways: 

By age (younger than six months, six months to 5 years, age five years and older),

By type (Umbilical, femoral, incisional, ventral, epigastric, umbilical, Spigelian), whether the physician previously repaired the hernia (initial, recurrent), Clinical presentation (reducible, incarcerated, strangulated, sliding).

Umbilical hernia repair CPT code(s) 49580-49587 includes mesh or other prostheses, do not report separately.

If CPT 49580-49587 in combination with Abdominal wall debridement (11042, 11043), report 11042, 11043 separately.

If umbilical hernia repair CPT code(s) 49580-49587 in combination with Intra-abdominal hernia repair/reduction (44050), report 44050 separately.

If CPT 49580-49587 in combination with repair or excision testicle(s), intestine, ovaries (44120, 54520, 58940), report (44120, 54520, 58940) separately. 

If evaluation management code (99202-99499) service performs for unrelated condition on the same day in conjunction with CPT 49580-49587. It is appropriate to report the E/M code with modifier 25 for an unrelated condition. Umbilical hernia repair CPT code(s) 49580-49587 has a 90-days global period time. 

In contrast, it is appropriate to report E/M code with modifier 24 in the post-operative period with the unrelated condition. Do not report E/M when the physician sees the patient for a related disease, including the global period.

Suppose unilateral umbilical hernia surgery performs by the physician, report with appropriate LT or RT modifier. In contrast, bilateral repair surgery served by the physician, reports with modifier 50.

Modifiers

The following are the list modifiers when CPT 49580-49587 bills:

22, 23, 47, 51, 52, 53, 58, 59, 76, 77, 78, 79, 99, AI, AQ, AR, CC, CR, ET, EY, FX, FY, GA, GC, GK, GR, GU, GY, GZ, KX, PT, Q5, Q6, QJ, SG, TC, XR, XP, XU, XS.

Modifier 76 is applicable with CPT 49580-49587 when a similar service performs by the Same Physician on the same service date.

Modifier 76 is applicable with umbilical hernia repair CPT code(s) 49580-49587 when a similar service performs by a different Physician on the same service date.

Modifier 59 is applicable with CPT 49580-49587 when a particular service performs by the physician and bundled with another procedure on the same date.  

Modifier X {E, P, S, U} is applicable instead of Modifier 59 with CPT 49580-49587 when service bills to medicare insurance. It divides the modifier into four parts for further specification of the procedure.

Modifier 53 will be reported with CPT 49580-49587 if unsuccessful hernia repairs occur due to unavoidable circumstances like allergic reactions to the substance.

Modifier 22 applies to CPT 49580-49587 when services perform longer than usual and take extra resources during the procedure.

Modifier 23 is applicable with CPT 49580-49587 when general or local anesthesia administers by the physician and routinely does not require during the procedure.

Modifier 52 applies when the physician does not complete the Umbilical hernia repair procedure and service terminates due to unavoidable circumstances.

If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and CPT 49580-49587 must apply the GA modifier to that service.

Examples

The following are the example when umbilical hernia repair CPT code(s) 49580-49587 bills:

Sample Operative Report

Date/Time:  Dec XX, 2022 

Procedure(s) Performed:      Robotic left incarcerated Umbilical hernia with the urinary bladder into the Supasac reinforced with Mesh. 

Pre-Operative Diagnosis:      Symptomatic Umbilical hernia partially incarcerated 

Post-Operative Diagnosis:      Incarcerated Umbilical hernia with sleeping of the urinary bladder into the Supasac through the Hesselbach triangle 

Primary Surgeon Surgeon (s):      Dr. ABC Assisted by:      Dr. XYZ Anesthesia Type:      General well-tolerated 

Justification for Procedure: This patient saw in my office with a chief complaint of a bulging mass in the left groin region, the testicle, and when standing up.

She was partially incarcerated and partially of Cord reducible. Very symptomatic. Patient discussed diagnosis alternative treatment risk and benefits. There is a scar in the right Umbilical area which reveals possible previous surgical repair of the right Umbilical hernia.

Patient does not remember what kind of surgery he had—the patient schedules for robotic Umbilical hernia repair, possibly open and reinforced with Mesh. Still, the incision position would be for a Right   Umbilical hernia repair with the Open technique. 

Description of Procedure(s): 

The patient intubates and placed in the supine position under general anesthesia. Abdomen prepped and draped with ChloraPrep in the usual fashion. 

Timeout conducts appropriately. 

The operation starts with the patient in reverse Trendelenburg. The Right lateral inclination replaces the Veress needle in the left upper quadrant to obtain pneumoperitoneum up to 15 mmHg with CO2 in place in the left position for the left-hand trocar.

A 5 mm trocar and a lens under vision administer into the peritoneal cavity with the Optiview. We put them right in the middle trochars for the right hand and the camera 30 degrees up.

We had the three trochars safely placed in the abdomen, put the patient in Trendelenburg, lowered the table, and corrected the inclination to 0 positions. 

The excited robotic platform then docks appropriately with a 30-degree camera. It performs with the help of the Left hand with a fenestrated grasper and bipolar energy in the right hand, scissors, and monopolar energy. 

The operation was started by declots sedating the Supasac over the direct hernia near the midline. The urinary bladder slipped into it. The sac and the bladder pull out.  

The surgeon opens the peritoneum above the defect, exposing the capsule back triangle and Cooper’s ligament.

The surgeon develops a flap of the peritoneum. Above the fault by opening from the medial to lateral the parietal peritoneum. 

Once the urinary bladder removes out of the incarcerated position, the lipoma also mobilizes to expose the transversalis fascia defect was closed with a running suture of nonabsorbable V-Loc suture; 

Then, we made room for the medium size left-sided Davol lightweight mesh inspection of the Cord revealed no indirect   Umbilical hernia. We placed a placental membrane on top of the Cord, and the Umbilical nerve set the Mesh to cover the defect sutured to Cooper’s ligament with an interrupted suture of 0 Prolene 

And then will suture lateral to the epigastric and medial to it with interrupted sutures of 2-0 Prolene. It fixes the Mesh in a geographic position to protect the indirect and then direct repair. 

All trochars removed under vision CO2 were evacuated from the peritoneal cavity. The peritoneal flap was then closed with a running suture of absorbable V-Loc 2 0 needle count sponge count, and instrument count where correct blood loss was minimal 1 to 2 mL. There was absolutely no indication of any injury to the hollow viscus. The skin approximates intradermic 4-0.

Finding(s):      As above 

Complications:      None 

Specimens Removed.      

None Implants/Explants:      Medium size left side Davol lightweight mesh for   Umbilical repair Estimated Blood Loss:      1 to 2 mL 

Patient Condition:      Good