Can we bill for an orchiopexy (54640) and an inguinal hernia repair (49495-49525) together, when the hernia repair is also performed through the one orchiopexy incision?
Excellent question, because the answer is not black-and-white. The rules are somewhat confusing in many areas and often inconsistent. Typically, CPT is the foundation for coding and reimbursement and rules for payment take into account CPT descriptions and included services.
CPT code 54640 (Orchiopexy, inguinal approach, with or without hernia repair) clearly states that hernia repair is included.
However, payer rules (in this case NCCI edits that can be viewed in AUACodingToday) show that the two codes, if billed for the same date of service, would be allowed. Payer rules usually trump CPT rules. There are many examples that state that you should follow payer rules if there is a conflict between CPT and the payer.
As CPT and payer rules are in conflict for this situation, we have implemented a general rule for coding these cases: Respecting what we believe is the intention of the CPT description, if the hernia repair is incidental, we will recommend not coding for the hernia repair. If documentation indicates that significant additional work to repair the hernia is required for the patient, as NCCI rules allow reporting of the hernia repair code in addition to the orchiopexy, we recommend reporting both codes instead of using modifier –22 on the orchiopexy code.
As you have heard many times before, private payer rules may vary, including the adoption of edits using the CPT language to deny payment for both. Follow the rules and your contract.