CPT® Code 49610

An omphalocele is a congenital defect characterized by a significant abnormality in the ventral abdominal wall, where there is a notable absence of essential structures such as abdominal muscles, fascia, and skin. This defect results in the protrusion of intra-abdominal organs, which are covered by a membrane composed of peritoneum and amnion. The most common form of omphalocele occurs at the umbilical ring, where the umbilical cord is directly attached to the omphalocele sac. The procedure coded as CPT® 49610 refers to the first stage of the surgical repair of an omphalocele, known as a Gross type operation. During this initial stage, critical steps are taken to manage the defect, including the ligation of umbilical vessels and the amputation of the umbilical cord. The surgical approach involves making an incision at the edge of the defect, followed by careful dissection of the skin from the underlying fascia, while ensuring that the amnion remains intact. The procedure culminates in the development of skin flaps that are then closed over the omphalocele, which results in the formation of a large ventral hernia. It is important to note that this is only the first stage of the repair; a subsequent stage, typically performed 6 months to 2 years later, involves the repair of the ventral hernia and the reopening of the skin flaps. For the second stage of the operation, the appropriate code is CPT® 49611.