Femoral Hernia Repair
4955049553wRVU: 9.67 — Femoral hernia, incarcerated or strangulated (initial)49555wRVU: 9.16 — Recurrent femoral hernia, reducible49557wRVU: 11.33 — Recurrent femoral hernia, incarcerated/strangulated44120wRVU: 20.3 — Small bowel resection (if strangulated bowel requires resection)
[Right / left] femoral hernia, [reducible / incarcerated / strangulated]
Same
[Right / left] femoral hernia repair, [low infrainguinal / McEvedy / Lotheissen approach], with [plug and patch mesh / Cooper's ligament repair / primary tissue repair]
[Attending name], MD
[Resident name]
[General / spinal / local with sedation]
Patient presents with a [right / left] femoral hernia, [reducible / incarcerated / acutely incarcerated with [X] hours of symptoms]. [Nausea/vomiting / bowel obstruction / peritonitis present.] Femoral hernias carry high risk of incarceration and strangulation; elective repair recommended for reducible hernias; emergent repair for incarcerated. Risks including femoral vein/artery injury, recurrence, nerve injury, and (if incarcerated) bowel resection discussed. Consent obtained.
[Reducible / incarcerated] femoral hernia containing [omentum / small bowel / Richter hernia: antimesenteric wall only]. Hernia sac [through the femoral canal, medial to the femoral vein]. [Contents viable after reduction / ischemic segment identified; resected]. Femoral canal [small / moderate sized].
[LOW INFRAINGUINAL (LOCKWOOD) APPROACH, for elective/reducible:] A [transverse] incision was made [1 cm below the inguinal ligament] directly over the hernia. The hernia sac was dissected free from the femoral canal. The sac was opened; [contents reduced / omentum ligated and excised]. The sac was ligated at its neck and excised. The femoral canal was closed by approximating Cooper's ligament to the inguinal ligament with interrupted [0-Prolene] sutures, taking care to avoid the femoral vein. [A plug of mesh was placed into the femoral canal and secured.]
[McEVEDY (HIGH) APPROACH, for incarcerated/strangulated:] A vertical [/ transverse] incision was made [above the inguinal ligament, medial]. The preperitoneal space was entered. The hernia sac was identified at the femoral canal from above. The incarcerated contents were reduced by gentle traction [/ the inguinal ligament was incised to enlarge the canal]. [Bowel viability assessed; viable / ischemic segment resected; see concurrent bowel resection note.] The defect was closed from above with [Cooper's ligament repair / mesh plug].
Hemostasis confirmed. Wound irrigated. Fascia closed with [2-0 Vicryl]. Skin closed with [3-0 Monocryl]. Patient tolerated the procedure well.
None
[Hernia sac / resected omentum / bowel to pathology / None]
Minimal
None
Patient to PACU. [Discharged same day / Admitted given bowel resection or acuity].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Right / left] femoral hernia, [reducible / incarcerated / strangulated]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Right / left] femoral hernia repair, [infrainguinal / McEvedy] approach, [plug and mesh / Cooper's ligament repair]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / spinal / local]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [right / left] [reducible / incarcerated] femoral hernia [with *** hours of symptoms]. Risks including femoral vein injury, recurrence, and bowel resection (if incarcerated) discussed. Informed consent obtained.
FINDINGS: Femoral hernia containing [omentum / small bowel / Richter]. Medial to femoral vein within femoral canal. Contents [viable / ischemic; resected].
DESCRIPTION OF PROCEDURE:
[INFRAINGUINAL: Transverse incision 1 cm below inguinal ligament; hernia sac dissected from femoral canal; sac opened; contents reduced [/ omentum ligated]; sac ligated and excised; femoral canal closed with Cooper's ligament-to-inguinal ligament interrupted 0-Prolene sutures avoiding femoral vein; mesh plug placed and secured.] [McEVEDY: Vertical incision above inguinal ligament; preperitoneal space entered; sac identified from above; contents reduced [/ inguinal ligament incised to enlarge canal]; bowel assessed; defect closed with Cooper's ligament repair / mesh.] Hemostasis. Fascia with 2-0 Vicryl; skin with 3-0 Monocryl. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. [Discharged / Admitted.]
Signed: .ME, .MYDEGREE
.TODAYVariants
Strangulated femoral hernia with bowel resection
CPT 49553 + 44120. McEvedy approach preferred, as it allows bowel resection through the same incision or via midline extension. Document bowel viability, resection length, and anastomosis technique. Mesh typically avoided in contaminated field.
Laparoscopic femoral hernia repair (TEP/TAPP)
Preperitoneal mesh covers the myopectineal orifice including the femoral space. Bill 49650 (laparoscopic inguinal hernia), as femoral hernia is included in the laparoscopic preperitoneal repair. Document that femoral space was visualized and covered.
Charting Tips
- Confirm the hernia is femoral (below inguinal ligament, medial to femoral vein) not inguinal, as anatomy drives CPT selection
- Document approach choice and rationale (infrainguinal for reducible, McEvedy for incarcerated)
- Note femoral vein identification and protection during Cooper's ligament repair
- State contents of hernia sac and viability
- {'If Richter hernia (partial bowel wall)': 'assess the pinched segment carefully, as bowel resection may be needed even if the hernia reduces easily'}
Billing Tips
- Bill 49550 for initial femoral hernia repair, any age, reducible (6.78 wRVU, 90-day global). Bill 49553 for initial femoral hernia, incarcerated or strangulated (10.01 wRVU). Bill 49555 for recurrent femoral hernia, reducible (8.97 wRVU). Bill 49557 for recurrent femoral hernia, incarcerated/strangulated (11.40 wRVU).
- Bowel resection for strangulated incarcerated femoral hernia: bill 44120 (small bowel resection) in addition to 49553. Document bowel viability assessment, resection extent, and anastomosis vs. ostomy. These are separately billable and not bundled.
- Do not use inguinal hernia codes (49505, 49507) for femoral hernia repair. They are different anatomic repairs with different CPT codes. Femoral hernias are below the inguinal ligament through the femoral canal, medial to the femoral vein.
- Mesh placement for femoral hernia repair: document mesh type and fixation. Mesh use does not change the CPT code for femoral hernia repair (unlike some inguinal hernia codes). Document plug or flat mesh technique.
- 90-day global: wound checks and routine follow-up are bundled. Recurrence within 90 days requiring re-operation uses modifier -78 and recurrent hernia codes apply thereafter.