Summary & Overview
CPT 49610: Omphalocele Repair, First-Stage Gross-Type
CPT code 49610 designates the initial Gross-type surgical repair for an omphalocele, a congenital abdominal wall defect typically addressed in the neonatal period. This code captures the first stage of a potentially staged reconstructive strategy for closing the abdominal wall and managing eviscerated contents. Nationally, accurate coding for neonatal abdominal wall repairs is critical for clinical tracking, quality reporting, and appropriate hospital reimbursement for complex operative and postoperative care.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a concise overview of coding definitions and clinical context, benchmark considerations for payer coverage patterns, and policy-relevant points that affect hospital and surgical services for congenital abdominal wall defects. Readers will find: an explanation of the procedure captured by the code; common sites of service and clinical teams involved; typical billing modifiers and coding considerations (listed separately); and how this procedure fits into staged care pathways for large omphaloceles.
The content is aimed at coding professionals, hospital billing managers, and clinical leaders seeking a clear reference for CPT code 49610, its clinical scope, and the payer landscape that influences authorization and reimbursement for neonatal surgical repair of omphaloceles.
Billing Code Overview
CPT code 49610 describes the first-stage Gross-type operation to repair an omphalocele, an abdominal wall defect in which abdominal contents protrude through the umbilical ring. This procedure involves initial surgical repair of the abdominal wall defect and may be part of a staged reconstructive approach for large or complex omphaloceles.
Service Type: Surgical — pediatric/neonatal abdominal wall repair
Typical Site of Service: Inpatient hospital operating room, often performed by pediatric surgery teams for neonates or infants with congenital abdominal wall defects.
Clinical & Coding Specifications
Clinical Context
A neonate is delivered with a congenital abdominal wall defect identified as an omphalocele, where abdominal contents protrude through the umbilical ring into a sac. The typical patient is a term or preterm newborn evaluated immediately after birth in the neonatal intensive care unit (NICU). Initial stabilization includes thermoregulation, airway assessment, intravenous access, fluid resuscitation, and protection of the sac with sterile, moist dressings and a plastic silo if the defect is large. Preoperative imaging (abdominal ultrasound or radiographs) and evaluation for associated anomalies (cardiac, chromosomal) are performed. The surgeon performs the first-stage Gross repair, 49610, which involves returning abdominal contents as tolerated, placing a silo for staged reduction if necessary, and approximating the abdominal wall. The clinical workflow includes preoperative consent, anesthesia evaluation (pediatric/neonatal anesthesia), operative staging with possible placement of a silo, postoperative NICU care with monitoring for respiratory compromise, feeding advancement when appropriate, and planning for subsequent definitive abdominal wall closure (second-stage procedures) if staged repair was performed. Typical site of service is the operating room within a tertiary pediatric hospital or children's hospital; emergent repairs may occur in centers with neonatal surgical capability.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Routine Modifier (no specific CMS meaning) |