Abdominal Hernia Defect Size

Question:

Our general surgeon often does not include the size of the abdominal repair in his documentation; can we use the pathology report to determine the correct size for CPT selection?

Answer:

No; the provider must document the hernia defect size within his/her operative report details to accurately select the correct CPT code. The pathology report would likely represent the tissue size, which would not necessarily correlate to the defect size. Best practice is to send a query to the provider asking him/her to add an addendum to the operative report, adding the defect size and advise that this information is required in the documentation.

*This response is based on the best information available as of 2/27/25.