Umbilical Hernia Repair
4959149592wRVU: 8.25 — Initial repair, <3 cm, incarcerated or strangulated (8.25 wRVU)49593wRVU: 10.0 — Initial repair, 3-10 cm, reducible (10.00 wRVU)49594wRVU: 13.12 — Initial repair, 3-10 cm, incarcerated or strangulated (13.12 wRVU)49595wRVU: 13.59 — Initial repair, >10 cm, reducible (13.59 wRVU)49596wRVU: 18.2 — Initial repair, >10 cm, incarcerated or strangulated (18.20 wRVU)
Umbilical hernia
Same
Umbilical hernia repair [primary suture / with mesh]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal / local with monitored anesthesia care
The patient is a [age]-year-old [male/female] with a symptomatic umbilical hernia measuring approximately [___] cm presenting for elective repair. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
An umbilical hernia was confirmed with a fascial defect measuring approximately [___] cm. The hernia sac contained [omentum/preperitoneal fat/no visceral contents]. The hernia was [easily reducible/mildly adherent]. [Additional findings or none].
The patient was brought to the operating room and placed supine. [Anesthesia type] was administered. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The umbilicus was prepped and draped in sterile fashion. A curvilinear infraumbilical or circumumbilical incision was made. Subcutaneous tissue was divided with electrocautery exposing the hernia sac. The sac was dissected circumferentially from the overlying skin and from the fascial edges. The sac was opened and the contents were reduced. The sac was excised and the fascial defect measured [___] cm.
[For primary repair:] The fascial edges were freshened. Primary repair was performed with [interrupted figure-of-eight 0-PDS / 0-Ethibond] sutures reapproximating the defect transversely without tension.
[For mesh repair:] A [polypropylene/composite/biologic] mesh measuring [___] x [___] cm was placed in the [underlay/onlay] position and secured with [interrupted transfascial 0-Prolene sutures / absorbable tacks]. The fascial edges were then reapproximated over the mesh with [interrupted 0-PDS] sutures.
The umbilical skin was reattached to the fascial repair with [3-0 Vicryl] sutures to recreate the umbilical dimple. Subcutaneous tissue was closed with [3-0 Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures. A sterile dressing was applied with umbilical packing as needed.
None
None / Hernia sac sent to pathology
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Umbilical hernia
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Umbilical hernia repair with ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a symptomatic umbilical hernia presenting for repair. Informed consent was obtained.
FINDINGS: Umbilical hernia with fascial defect *** cm, containing ***. Hernia was ***.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. *** anesthesia administered. Surgical timeout performed per protocol.
A circumumbilical incision was made. The hernia sac was dissected, contents reduced, and sac excised. Defect measured *** cm. The defect was repaired with ***. The umbilical skin was tacked to the repair. Skin closed with 4-0 Monocryl. Sterile dressings applied.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Incarcerated Umbilical Hernia
The hernia was found to contain [omentum/small bowel] that could not be reduced preoperatively. After opening the sac, the fascial ring was carefully extended with cold scissors (sharp dissection, not electrocautery, to avoid thermal injury to incarcerated bowel) to allow safe reduction. The [omentum/bowel] was inspected and found to be [viable/pink with intact vascularity]. [If omentum non-viable: a portion of non-viable omentum was resected.] The contents were reduced and repair proceeded as described.
Umbilical Hernia in Cirrhotic Patient / Ascites
Given the patient's underlying cirrhosis and ascites, particular care was taken to control ascitic fluid loss during the procedure. The hernia sac was entered and fluid was suctioned. The defect was repaired with a primary figure-of-eight closure using non-absorbable suture to minimize risk of recurrence. [Mesh was avoided/used] given the risk of [infection/recurrence]. Anesthesia was alerted to fluid losses. [TIPS placement/optimization of diuretic therapy] was coordinated perioperatively.
Charting Tips
- Document defect size in centimeters. EHS/AHS 2020 guidelines recommend mesh for defects greater than 1 cm given higher recurrence rates with primary repair. Documenting the size supports the technique chosen and determines the CPT code.
- Record whether the umbilical skin was preserved and tacked down. Cosmetic outcome is a key patient concern for this procedure and umbilical reconstruction should be in the note.
- For cirrhotic patients, document the perioperative optimization and ascites management. These patients have significantly higher complication rates and the note should reflect the risk modification efforts.
Billing Tips
- Bill 49591 for initial umbilical or epigastric hernia repair, defect less than 3 cm, reducible (5.81 wRVU, 0-day global). Bill 49592 for the same defect size, incarcerated or strangulated (8.25 wRVU).
- For larger defects: 49593 for 3-10 cm reducible (10.00 wRVU), 49594 for 3-10 cm incarcerated/strangulated (13.12 wRVU), 49595 for greater than 10 cm reducible (13.59 wRVU), 49596 for greater than 10 cm incarcerated/strangulated (18.20 wRVU). These codes (effective 2022) replaced the retired 49585/49587 codes and apply to umbilical, epigastric, and small midline ventral hernias.
- Document hernia defect size in centimeters, reducibility, and whether incarceration or strangulation was present. These three factors determine the correct code. There is no separate code for mesh use within this series.
- 0-day global period. Routine follow-up visits and wound checks are separately billable. Seroma aspiration is not bundled.
- For umbilical hernias repaired incidentally during another abdominal procedure, bill with modifier -51. Document the decision to repair and note it as a separately identifiable procedure.