CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP012

Hernia Repair Coding and Reimbursement

Governs coding and reimbursement practices for hernia repair procedures for providers submitting claims to Blue Cross Blue Shield New Mexico; applies to facilities, physicians, and other qualified health care professionals delivering these services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHernia Repair Coding and Reimbursement

Policy CodePolicy CPCP012

Change TypeNo material change

Effective DateMay 15, 2023

Next Review Date

Key ActionSubmit supporting documentation upon request and ensure accurate coding using HIPAA-approved code sets.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

May 15, 2023effective date

multiplecovered hernia types

49591-49623example CPTs referenced

doc requiredunlisted code requirement

Coverage and Billing Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

General coding and reimbursement criteria

Covered when administrative and coding requirements below are followed:

Inclusion of a code in this policy does not guarantee coverage or reimbursement; exclusions may apply under benefit plans or other plan documents.

Providers must accurately, completely, and legibly document services performed and code using HIPAA‑approved code sets and industry coding guidelines; revenue and procedure codes must reflect the diagnosis and services rendered.

Claims are subject to code edit protocols and case‑by‑case review including benefit coverage, provider contract language, medical policies, and coding software logic; BCBSNM may request supporting documentation.

Parastomal hernia coding rules

Use the following CPT coding conventions for parastomal hernia repairs:

Use CPT 49621 for repair of a reducible parastomal hernia.

Use CPT 49622 for repair of an incarcerated or strangulated parastomal hernia.

Report add‑on CPT +49623 only in conjunction with CPT 49622.

Parastomal hernia coding and documentation rules

Billing and documentation guidance for parastomal hernia procedures:

Use CPT 49621 for repair of a reducible parastomal hernia.

Use CPT 49622 for repair of an incarcerated or strangulated parastomal hernia.

Report add‑on CPT +49623 only in conjunction with CPT 49622.

When a hybrid laparoscopic and open repair is performed, include the applicable code for the open hernia repair.

If unlisted or miscellaneous procedure codes are submitted, submit supporting documentation; unlisted codes must be used only when no existing code adequately describes the overall procedure and outcome.

Hernia repair coverage and billing rules

Claims coding and billing rules included in this document segment:

Use CPT 49621 for reducible parastomal hernia repair; use CPT 49622 for incarcerated or strangulated parastomal hernia repair; add‑on CPT +49623 may be reported only in conjunction with CPT 49622.

Hybrid laparoscopic and open repairs should include the applicable open hernia repair code.

When hernia repair is billed on the same date as certain bariatric surgery codes, hernia repair may be considered integral or mutually exclusive; providers should verify member benefit coverage and exclusions for bariatric surgery and related complications.

Unlisted procedure codes require supporting documentation and should be used only when no existing code adequately describes the procedure and outcome.

Procedure Codes and Coding Guidance

Referenced CPT codes for hernia repairsCPT

49591-49596	Anterior abdominal hernia repair codes referenced (epigastric, incisional, spigelian, umbilical, ventral).
49613-49618	Additional anterior abdominal/ventral hernia repair codes referenced.
39501, 39503, 39540, 39541, 39545, 39560, 39561, 39599	Diaphragmatic/related codes referenced.
49540	Lumbar hernia repair.
49600-49611	Omphalocele-related codes (including removal of prosthesis etc.).
49621, 49622, +49623	Parastomal hernia repair codes; +49623 is an add-on applicable with 49622.
49550, 49553, 49555, 49557	Femoral/inguinal related codes referenced.

Parastomal hernia repairCPT

49621	Repair of reducible parastomal hernia
49622	Repair of incarcerated or strangulated parastomal hernia
+49623	Add-on code; reported in conjunction with 49622

Parastomal hernia procedure codesCPTCovered

49621	Repair of reducible parastomal hernia
49622	Repair of incarcerated or strangulated parastomal hernia
+49623	Add-on code; reported in conjunction with 49622

Parastomal hernia repair codesCPT

49621	Repair of reducible parastomal hernia
49622	Repair of incarcerated or strangulated parastomal hernia
+49623	Add-on code to be reported in conjunction with 49622

Parastomal hernia repair codesCPT

49621	Repair of reducible parastomal hernia
49622	Repair of incarcerated or strangulated parastomal hernia
+49623	Add-on code to be used in conjunction with 49622

Parastomal hernia repair codesCPTCovered

49621	Repair of reducible parastomal hernia
49622	Repair of incarcerated or strangulated parastomal hernia
+49623	Add-on code to report in conjunction with 49622

Unlisted code documentation — supporting documentation required when unlisted/misc codes are submitted

When to useSubmit supporting documentation whenever unlisted or miscellaneous procedure codes are billed; unlisted procedure codes must be used only when no existing code adequately describes the overall procedure and outcome.

Required documentationClinical operative report and rationale describing why an existing CPT code does not adequately describe the procedure, plus relevant imaging, pathology, and anesthesia records as requested.

Claim handlingClaims with unlisted/NOC codes are subject to review and may trigger requests for additional documentation; lack of supporting documentation may result in denial or delay.

Policy referenceSee related policy CPCPLAB012 and CPCP035 for pre-operative testing and Unlisted/NOC coding guidance.

Provider Billing Actions and Documentation

Documentation Required

Documentation requests and discretionary authority

BCBSNM may request supporting documentation and has discretionary authority to interpret and apply this policy to services delivered in specific cases. Providers are responsible for accurate submission of documentation and coding using HIPAA‑approved code sets and standard coding guidelines. Claims are subject to review against plan benefits, provider contracts, medical and coding policies, and code‑editing logic; additional documentation should be submitted upon request.

Billing Rule

Parastomal hernia repair codes

CPT code 49621 is used for repair of a reducible parastomal hernia; CPT code 49622 is reported for an incarcerated or strangulated parastomal hernia. Add‑on CPT code +49623 may be reported in conjunction with 49622.

Affected CPT codes: 49621, 49622, +49623

Billing Rule

Parastomal hernia CPT coding guidance

When coding parastomal hernia repairs, report 49621 for reducible hernias and 49622 for incarcerated/strangulated hernias. Use add‑on code +49623 only with 49622 when appropriate.

Use 49621 for reducible parastomal hernia repair
Use 49622 for incarcerated or strangulated parastomal hernia repair
+49623 is an add‑on and may be used only with 49622

Billing Rule

Parastomal hernia CPT coding

CPT guidance: 49621 — reducible parastomal hernia repair; 49622 — incarcerated or strangulated parastomal hernia repair. +49623 is an add‑on code intended to be reported with 49622 when applicable.

49621 — reducible parastomal hernia
49622 — incarcerated/strangulated parastomal hernia
+49623 — add‑on; report with 49622 only

Billing Rule

Parastomal hernia CPT coding notes

Add‑on code +49623 is reportable only with 49622. Do not report +49623 with 49621.

+49623 only in conjunction with 49622

Documentation Required

Unlisted procedure code documentation requirement

If unlisted or miscellaneous procedure codes are submitted on a claim, supporting documentation must be submitted to explain the procedure performed and why no existing code describes it. Unlisted procedure codes must be used only when the overall procedure and outcome are not adequately described by an existing procedure code. Failure to submit required supporting documentation may result in claim denial or processing delays.

When submitting an unlisted procedure code, include operative report and documentation describing the procedure and outcome
Unlisted codes should be used only if no existing code adequately describes the service
Supporting documentation must be provided upon request to avoid denials or delays

Billing Rule

Hybrid procedure coding rule

For hybrid procedures that combine laparoscopic and open techniques during a hernia repair, report the applicable open hernia repair code in addition to any other appropriate codes per coding conventions and payer guidance.

When both laparoscopic and open techniques are used, include the open hernia repair code

Definitions and Terms

Plan documents — plan documents definition

DefinitionPlan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents; plan documents govern in the event of a conflict with this CPCP.

AuthorityIf a CPCP conflicts with a plan document, the plan document will govern; if it conflicts with a provider contract, the provider contract will govern.

DiscretionBCBSNM may use reasonable discretion in interpreting and applying this policy to services being delivered in a particular case; BCBSNM has full and final discretionary authority as provided under applicable plan documents.

Parastomal hernia — definition and code pointers (49621 reducible, 49622 incarcerated/strangulated)

DefinitionParastomal hernia: occurs when part of the stomach, small bowel, or colon protrudes through a stoma.

Associated CPT codesUse CPT 49621 for repair of a reducible parastomal hernia and CPT 49622 for repair of an incarcerated or strangulated parastomal hernia; add-on +49623 may be used with 49622.

Clinical noteCoding depends on reducibility and presence of incarceration/strangulation; documentation should support the clinical condition reported.

Anterior abdominal hernia — definition and code considerations

DefinitionAnterior abdominal hernia includes epigastric, incisional, spigelian, umbilical, and ventral hernias; codes vary by surgical approach, defect size, and whether the hernia is incarcerated or strangulated.

Coding considerationsSelect codes based on approach and size; some anterior abdominal hernia codes describe incarceration/strangulation and others allow add-on +49623 in certain contexts.

Associated codesExamples include 49591–49596 and 49613–49618 among others; verify the code set that matches the procedure description.

Parastomal hernia CPT coding — summary of 49621, 49622, +49623

49621CPT 49621 — repair of a reducible parastomal hernia.

49622CPT 49622 — repair of an incarcerated or strangulated parastomal hernia.

+49623CPT +49623 — add-on code that may be reported in conjunction with CPT 49622.

reducible parastomal hernia — short definition

Short definitionReducible parastomal hernia: a herniation through a stoma that can be reduced (manually or spontaneously) back into the abdominal cavity.

Primary codeReport CPT 49621 for repair when the hernia is documented as reducible.

DocumentationOperative and clinical notes should document reducibility to support use of 49621.

incarcerated/strangulated parastomal hernia — short definition

Short definitionIncarcerated or strangulated parastomal hernia: a parastomal hernia with compromised reducibility often associated with obstruction or ischemia.

Primary codeReport CPT 49622 for repair when the hernia is documented as incarcerated or strangulated.

Add-on guidance+49623 may be reported in conjunction with 49622 when applicable; documentation should reflect the additional procedure component.

Parastomal hernia repair coding — CPT 49621/49622 summary

Primary codesCPT 49621 — repair of reducible parastomal hernia; CPT 49622 — repair of incarcerated or strangulated parastomal hernia.

Add-on allowanceAdd-on CPT +49623 may be reported in conjunction with CPT 49622.

Coding practiceEnsure operative documentation supports the choice of 49621 vs 49622 and any use of +49623; hybrid procedures should include the open repair code when applicable.

+49623 / 49621 / 49622 — add-on code definition and pairing guidance

DefinitionAdd-on CPT +49623 is an additional procedure code reported only in conjunction with primary CPT 49622 for parastomal hernia repairs.

Pairing guidance+49623 should be reported only with 49622 (incarcerated/strangulated repairs) per this policy; do not report +49623 alone.

DocumentationWhen +49623 is billed, documentation must justify the additional procedure component and its relationship to the primary 49622 procedure.

Unlisted procedure codes — definition and documentation requirement

DefinitionUnlisted procedure codes are codes used only when no existing CPT code adequately describes the overall procedure and outcome.

Use requirementUse unlisted codes only when necessary; when submitted, include supporting clinical and operative documentation explaining why an existing code is inadequate.

Review consequenceClaims with unlisted codes will require supporting documentation and are subject to additional review or request for information.

+49623 — add-on CPT code definition

Definition+49623 — an add-on CPT code to be reported in conjunction with CPT 49622 for parastomal hernia repairs.

Billing ruleDo not report +49623 without the primary procedure code 49622; pairings outside of 49622 are not supported by this policy.

DocumentationWhen billing +49623, include operative detail describing the additional procedural work that justifies the add-on code.

Preoperative testing window — governed by CPCP038 (date of admission and up to three calendar days before)

Window definitionPreoperative testing performed on the date of admission and up to three calendar days preceding the date of admission is governed by CPCP038 Outpatient Services Prior to an Inpatient Admission.

Action for providersRefer to CPCP038 for coverage and billing rules for preoperative testing within this timeframe.

Related policiesSee CPCPLAB012 for pre-operative testing details and CPCP035 for unlisted/NOC coding guidance when tests are billed separately.

OpenPayer

Hernia Repair Coding and Reimbursement

Coverage and Billing Criteria

Procedure Codes and Coding Guidance

Provider Billing Actions and Documentation

Definitions and Terms

Policy Revision History