Medicare reimbursement codes for hernia procedures have small impact on patients

Medicare reimbursement codes for hernia procedures are often tied to disease severity and acuity.

At the beginning of 2023, the Centers for Medicare and Medicaid Services made significant changes to these coding guidelines tied to the reimbursement for anterior abdominal hernia repair.

These changes state that the threshold for higher reimbursement is now a hernia that is three centimeters in size or larger.

Previously, total hernia defect size was not a factor when it came to hernia repair reimbursement.

With hernia size determining reimbursement moving forward, University of Michigan Health professor of surgery, Dana Telem, M.D., led a team of researchers to examine the association between this coding change and the documented hernia size in a state of Michigan hernia data registry.

Using data from a statewide clinical hernia registry representing nearly 90% of the hospitals in Michigan, Telem and team examined the documented hernia size before and after the coding changes took effect on January 1, 2023.

The data revealed a total of 60% of the hernias in the group with procedures before the policy took effect were classified as smaller than three centimeters. 

After the coding change, only 49.3% of hernias were classified as smaller than three centimeters.

“There is no average size of hernia in the United States and the change in average size of hernias reported pre and post reimbursement policy change is very minimal taking into account that this study only looked at reports from one state,” said Telem.

“Medicare recipients should not expect this change to impact their bill or the value of care they receive.”

For hernias, the only treatment option currently is surgical removal. However, not all hernias need to be surgically removed as some are okay to stay in the body for prolonged periods of time. 

Telem recommends that if there are concerns about the cost of a hernia procedure, it is important to talk with your provider about the best path of care.

Additional authors: Alexander Hallway, B.A., from the University of Michigan Department of Surgery, and the University of Michigan Department of Learning Health Sciences, Ann Arbor, MI. Erin Isenberg, M.D. from the University of Michigan Center for Healthcare Outcomes & Policy, Ann Arbor, MI and the University of Texas Southwestern Medical Center, Dallas, TX. Ryan Howard, M.D., M.S., Sean O’Neill, M.D., Ph.D., Lea Schoel, M.D., and Ann Ehlers, M.D., M.P.H., from the University of Michigan Department of Surgery and the University of Michigan Center for Healthcare Outcomes & Policy, Ann Arbor, MI. Jenny Shao, M.D., from the University of Michigan Department of Surgery, Ann Arbor, MI. Michael Rubyan, Ph.D., M.P.H., from the University of Michigan Department of Health Management and Policy, Ann Arbor, MI.

Funding: All of work is funded through grants from the NIDDK

Tech transfer(s)/Conflict(s) of interest: Ehlers reported receiving grants from NIH/NIDDK during the conduct of the study. Shao reported receiving honoraria for consulting from AbbVie outside the submitted work. Telem reported receiving grants from NIDDK (R01DK128179-O1A1) during the conduct of the study.

Paper cited: “Medicare Coding Changes and Reported Hernia Size,” JAMA. DOI: 10.1001/jama.2024.26829