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PREOPERATIVE/POSTOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia.
PROCEDURE PERFORMED: Laparoscopic right inguinal herniorrhaphy with mesh.
BRIEF HISTORY: This patient is a 66-year-old African American male who presented to Dr. Y’s office with recurrent right inguinal hernia for the second time, requesting hernia repair. History of attempt at open inguinal repair on the right. The procedure was discussed with the patient and the patient opted for laparoscopic repair due to the minimally invasive nature of this technique.
INTRAOPERATIVE FINDINGS: The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced.
PROCEDURE: The risks and benefits of the procedure were explained to the patient and informed consent was obtained. The patient was brought to an operating suite after general endotracheal intubation and then prepped and draped in the normal sterile fashion. An infraumbilical incision was made with a #15 Bard-Parker scalpel. The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty. Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mm Hg. Next, the Veress was removed, and a #10 bladed trocar was inserted without difficulty. The 30-degree camera laparoscope was then inserted, and the abdomen was explored. There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible. Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus. Again, a skin incision was made with a #15 blade scalpel, and the #12 port was inserted under direct visualization. A #5 port was inserted in the left upper quadrant in a similar fashion without difficulty under direct visualization. Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac, and using Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral. The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty. Dissection was carried out, freeing up the hernia sac from the peritoneum. This was done without difficulty, reducing the hernia in its entirety. Attention was next made to placing a piece of Prolene mesh: It was inserted through the #12 port and placed into the desired position and its medial aspect was stapled into place via 4 mm staples along the iliopubic tract. The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples. This was done without difficulty. All three ports were removed under direct visualization. No evidence of bleeding, and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle. Skin was closed with running subcuticular #4-0 undyed Vicryl. Steri-Strips and sterile dressings were applied. The patient tolerated this procedure well and was transferred to recovery after extubation in stable condition.
Code the Diagnosis
K40.91 Unilateral inguinal hernia, without obstruction or gangrene, recurrent
Rationale: The codes for hernias in ICD-10-CM are broken down by type, laterality, with/without obstruction, with/without gangrene, and whether or not the hernia is recurrent. In this scenario, the patient presented with a right (laterality) inguinal (type) hernia that was recurrent. There is no mention of obstruction or gangrene in the operative note, so the code for “without obstruction or gangrene” is assigned.
2021 ICD-10-CM code book