CPT 49505: Repair Initial Inguinal Hernia, Child 5 Years or Older
Medicare pays $514 and commercial payers pay $2080 on average nationally for this procedure.
CPT code 49505 describes surgical repair of an initial inguinal hernia in a child five years of age or older where the provider reduces the hernia prior to repair; the service is a pediatric inguinal hernia repair (open surgical procedure) typically performed in an operating room or ambulatory surgery center under general anesthesia or appropriate regional/local anesthesia for the patient’s age and condition.
For related coverage guidance, see recent payer policy updates: Dental Anesthesia Services, Anesthesia Services for Interventional Pain Management Procedures in an Adult, General Anesthesia and Conscious Sedation Services.
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National Reimbursement Benchmarks
Commercial averages sit well above Medicare for CPT 49505: Blue Cross Blue Shield and BUCA show mean rates of $3,059.20 and $2,080.10 respectively, compared with Medicare’s mean of $513.80. This places BUCA roughly four times Medicare’s average and Blue Cross Blue Shield about six times higher, underscoring substantial upward pressure from commercial contracts versus the Medicare baseline.
Rate dispersion (P75 minus P25) highlights where pricing is tight or wide. Blue Cross Blue Shield has the widest interquartile spread at $3,747.00 ($4,783.10 − $1,036.10), followed by UnitedHealth Group at $5,860.00? Wait—must calculate correctly: UnitedHealth Group P75 $1,150.40 minus P25 $564.40 equals $586.00. Cigna’s spread is $547.00 ($1,099.60 − $519.70), BUCA’s spread is $2,398.80 ($3,165.50 − $766.70), Aetna’s spread is $389.40 ($776.00 − $138.60), and Medicare’s spread is $41.00 ($534.00 − $493.00). Thus Blue Cross Blue Shield and BUCA show the widest dispersion, while Medicare and Aetna are the tightest.