Repair initial inguinal hernia, age 5 years or older; reducible
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Hernia repair medical necessity - symptomatic vs asymptomatic, age criteria
Common49505 (inguinal hernia repair, age 5 years or over) requires symptomatic hernia or risk of complications. Denied when: asymptomatic hernia without indication for repair, imaging doesn't confirm hernia clinically suspected, wrong code for age (pediatric codes for age <5), or recurrent hernia billed as initial repair. Asymptomatic inguinal hernias in adults have watchful waiting as acceptable option.
Common Causes
- • Asymptomatic hernia on imaging, patient wants elective repair - may not be covered without symptoms
- • Hernia suspected on exam but not confirmed by imaging (ultrasound or CT)
- • Recurrent hernia but initial repair code billed - should use recurrent hernia code 49520
Resolution Strategy
Document symptomatic hernia: 'Patient age 52 with right inguinal hernia, 6-month history progressive enlargement. Symptoms: daily groin pain with standing/lifting, limits work activities (construction), intermittent nausea when hernia enlarges. Physical exam: 4cm inguinal hernia, easily reducible, cough impulse positive. Ultrasound confirms right inguinal hernia with bowel contents. Symptomatic inguinal hernia requiring surgical repair per ACS guidelines. Open inguinal hernia repair with mesh planned.' Alternative: 'Incarcerated right inguinal hernia presenting to ED. Unable to reduce manually. CT shows incarcerated hernia containing sigmoid colon without evidence of strangulation. Urgent surgical repair indicated to prevent strangulation. Emergency hernia repair performed.' Must document: hernia location, symptoms (pain, discomfort, limiting activities), physical exam (size, reducibility), imaging confirmation, indication for repair (symptomatic vs incarcerated). Asymptomatic hernias: watchful waiting may be appropriate, repair optional. Age <5 use pediatric code. Recurrent hernia different code.
Relative Value Units (RVUs)
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Clinical Information
When to Use
For open repair of reducible inguinal hernia in patients age 5 years or older
Common Scenarios
Documentation Requirements
- Hernia location (direct vs indirect inguinal)
- Size and reducibility of hernia
- Surgical approach (anterior vs posterior)
- Type of mesh used (if applicable)
- Fascial closure technique
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes hernia sac dissection and reduction
- Includes mesh placement if performed
- Includes fascial repair and closure
- Local anesthesia bundled when performed same session
- Exploration of contralateral side bundled
Exclusions
- 49507 (incarcerated or strangulated hernia)
- 49520 (recurrent inguinal hernia)
- 49650 (laparoscopic inguinal hernia repair)
Coding Notes
Clinical scenarios
- Hernia location (direct vs indirect inguinal)
- Size and reducibility of hernia
- Surgical approach (anterior vs posterior)
- Hernia location (direct vs indirect inguinal)
- Size and reducibility of hernia
- Surgical approach (anterior vs posterior)
- Hernia location (direct vs indirect inguinal)
- Size and reducibility of hernia
- Surgical approach (anterior vs posterior)
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Ask a QuestionFrequently Asked Questions
CPT 49505 is the billing code for "Repair initial inguinal hernia, age 5 years or older; reducible". For open repair of reducible inguinal hernia in patients age 5 years or older
Medicare pays approximately $515.60 for CPT 49505 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 49505 has a total RVU of 21.25, broken down as: Work RVU 9.50, Practice Expense RVU 10.80, and Malpractice RVU 0.95. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 49505 is "Hernia repair medical necessity - symptomatic vs asymptomatic, age criteria". 49505 (inguinal hernia repair, age 5 years or over) requires symptomatic hernia or risk of complications. Denied when: asymptomatic hernia without indication for repair, imaging doesn't confirm hernia clinically suspected, wrong code for age (pediatric codes for age <5), or recurrent hernia billed as initial repair. Asymptomatic inguinal hernias in adults have watchful waiting as acceptable option. Common causes include: Asymptomatic hernia on imaging, patient wants elective repair - may not be covered without symptoms; Hernia suspected on exam but not confirmed by imaging (ultrasound or CT). Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 49505 include: Hernia location (direct vs indirect inguinal); Size and reducibility of hernia; Surgical approach (anterior vs posterior); Type of mesh used (if applicable). Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 49505: Includes hernia sac dissection and reduction. Includes mesh placement if performed Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 49505 include: 50 (Bilateral procedure when both sides repaired same session), 51 (Multiple procedures performed same session), 22 (Increased procedural services for complex repair). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 49505 is 45-75 minutes typical operative time. Time-based codes require documentation of the actual time spent providing the service.