Summary & Overview
CPT 49611: Second-Stage Gross Repair of Omphalocele
CPT code 49611 denotes the second-stage Gross-type surgical repair of an omphalocele, a congenital abdominal wall defect. This procedure completes staged abdominal wall reconstruction after initial neonatal or pediatric stabilization. Nationally, the code is relevant for pediatric surgeons, neonatology teams, and hospital surgical departments managing complex abdominal wall defects; it also affects billing and coverage workflows for inpatient surgical services.
Key payers covered in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical intent of the code, the typical procedural setting, and which major payers are relevant to coverage and claims processing. The publication summarizes common billing modifiers associated with complex surgical services and highlights the clinical context of staged omphalocele repair.
This content provides benchmarks and policy context useful to coding managers, billing teams, and clinical program leaders. It outlines what to expect in claims adjudication for staged abdominal wall reconstruction, clarifies typical sites of service, and identifies areas where policy updates or payer-specific guidance may affect reimbursement and documentation requirements.
Billing Code Overview
CPT code 49611 describes the second stage of a Gross-type surgical repair of an omphalocele, an abdominal wall defect in which abdominal contents protrude through the umbilical area. The procedure focuses on reconstructing the abdominal wall and completing staged closure following initial management of the omphalocele.
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Service type: Surgical procedure — abdominal wall reconstruction (second-stage repair)
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Typical site of service: Operating room or inpatient surgical suite for pediatric or neonatal surgical care
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Clinical & Coding Specifications
Clinical Context
A newborn infant with a congenital abdominal wall defect (omphalocele) undergoes staged surgical repair. Typically, a neonate is evaluated in the neonatal intensive care unit with multidisciplinary input from pediatric surgery, neonatology, and pediatric anesthesia. Initial management focuses on protecting the sac, maintaining thermoregulation, fluid and electrolyte balance, and treating associated anomalies. The first stage (initial closure or silo placement) is performed soon after birth if direct closure is unsafe. After gradual reduction of viscera and improved abdominal domain, the provider performs the second stage — a definitive closure of the abdominal wall (Gross type repair) under general anesthesia in the operating room. The clinical workflow includes preoperative assessment, consent, perioperative antibiotic prophylaxis, general endotracheal anesthesia, possible blood product availability, intraoperative repair of fascia and skin layers, and postoperative monitoring in the neonatal intensive care unit or pediatric surgery step-down unit for respiratory support, pain management, and wound care. Typical payors involved include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare depending on patient coverage and age.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier / standard claim | Use when no other modifier applies and the service is reported in the usual manner. |