Strengthen 
Weak ICD-10 Hernia Coding

Reinforce good diagnosis coding by recognizing symptoms and four essential documentation elements.

Hernia is a general term to describe a bulge or protrusion of an organ through the structure or muscle that usually contains it. Hernias can occur throughout the body (for instance, a herniated intervertebral disk), but most commonly occur into or through a weakness in the abdominal wall.
An abdominal hernia occurs when the fascia develops a tear, and the peritoneal lining “spills out.” In some cases, only an empty sac protrudes through the fascia. If the fascial defect is large enough, however, the sac can contain abdominal contents (typically, intestines).

Review of Symptoms

Common symptoms of hernia vary, depending on the type. For asymptomatic hernia, the patient may have swelling or fullness at the hernia site. Although there’s little pain or tenderness, the patient may have an aching sensation that radiates into the area of the hernia. The hernia normally enlarges with increasing intra-abdominal pressure and/or standing.
Incarcerated hernias have painful enlargement of the hernia defect. The herniated contents cannot be manipulated either via manual manipulation or spontaneous reduction back through the fascial defect. The patient could experience nausea, vomiting, and symptoms of bowel obstruction, depending on the incarcerated tissue involved.
Strangulated hernia is a hernia so tightly constricted that it compromises the blood supply of the hernia sac, leading to gangrene of the sac and its contents. Common symptoms include systemic toxicity secondary to an ischemic bowel, and pain and tenderness of an incarcerated hernia that persists after reduction.

Look for Four Key Documentation Elements

When selecting ICD-10 codes for hernia, consider four documentation elements:
1. Type
Clinicians identify hernias primarily by location or type. Common hernia types include:
Inguinal: In this common form of hernia (75 percent of all hernias are of the inguinal variety), the intestine bulges through a weak area in the inguinal canal in the groin area. Inguinal hernias may be either direct (congenital) or indirect (acquired).
Femoral: These hernias occur in the area between the abdomen and the thigh, usually appearing as a bulge on the upper thigh.
Umbilical: The fascia of the navel is thinner than in the rest of the abdomen. An umbilical hernia occurs when contents protrude from the navel.
Ventral/Incisional: A defect in the abdominal wall at the site of a previous operative incision.
Diaphragmatic: A defect in the diaphragm (congenital or acquired) allows contents from the abdominal cavity to spill into the chest cavity.
Each of the above categories may include specific subcategories (e.g., femoral hernias include paraumbilical hernias). Additional hernia types include lumbar hernia, obturator hernia, pudendal hernia, and others.
2. Laterality
The concept of laterality only applies to inguinal and femoral hernias. For these hernia types, provider documentation must specify whether the hernia is bilateral or unilateral.
3. Complicated By
Complications of hernia include possible obstruction (documentation stating incarcerated, irreducible, or strangulated implies this) and the presence of gangrene.
If the provider can manually push the contents of the hernia sac (e.g., the intestine, in the case of an inguinal hernia) back through the fascial defect, the hernia is reducible. In some cases, the contents of the hernia sac become trapped in the opening caused by the fascial defect. Such incarcerated or strangulated hernias cannot be reduced and pose potential life-threatening danger.
A note at the beginning of the Hernia section in ICD-10-CM instructs that if a hernia has both obstruction and gangrene to classify it as having gangrene.
4. Temporal Parameters
Temporal parameters include status of recurrent and not specified as recurrent (e.g., Is this the first hernia at this location?).

Code Categories

Hernia codes (K40–K46) include acquired hernias, congenital hernias (except diaphragmatic or hiatus), and recurrent hernia.
Inguinal hernia K40-K40.91: This subcategory includes codes for direct inguinal, double inguinal, indirect, oblique inguinal, and scrotal hernias. To assign a code, you must know the location and laterality of the hernia, whether it’s with or without obstruction, whether it’s recurrent, and if there is gangrene present.
Femoral hernia K41.0-K41.91: This subcategory includes codes for paraumbilical hernias. To assign a code, you must know if the hernia is bilateral or unilateral, with or without obstruction, whether it’s recurrent, and if there is gangrene present.
Umbilical hernia K42-K42.9: To assign a code from this subcategory, you must know the hernia has an obstruction and/or gangrene present. An excludes 1 note with this category indicates that if an omphalocele (Q79.2 Exomphalos) is present, do not report these two codes together.
Ventral hernia K43.0-K43.9: To assign a code from this subcategory, know if the hernia is classified as an incisional hernia or a parastomal hernia, and if there is an obstruction and/or gangrene present.
Diaphragmatic hernia K44.0-K44.9: To assign a code from this subcategory, know if there is an obstruction and/or gangrene present. This code category includes hiatal hernia and esophageal or sliding hernia. There is an excludes 1 note that indicates not to report a congenital diaphragmatic hernia (Q79.0 Congenital diaphragmatic hernia) or a congenital hiatus hernia (Q40.1 Congenital hiatus hernia) at the same time as a code from this subcategory.
Other abdominal hernia K45-K45.8: This subcategory includes abdominal hernia, specified site, not elsewhere classified; lumbar hernia; obturator hernia; pudendal hernia; retroperitoneal hernia; and sciatic hernias. To assign a code, you must know if there is an obstruction and/or gangrene present.
Unspecified abdominal hernia K46-K46.9: Use a unspecified code only if documentation is imprecise and there is no way to query the reporting provider for more detail.

Examples Build Coding Confidence 

Example 1: A 78-year-old man presented with a two-day history of a painful mass in his right groin. Abdominal examination disclosed mild tenderness in the right lower quadrant. A 6 cm right inguinal mass was palpated that was non-reducible and exquisitely tender to palpation. At laparotomy, a large, edematous, inflamed femoral mass medial to the femoral vein was identified. The anterior surface was opened and purulent fluid was drained. The femoral hernia was repaired by suturing the iliopubic tract to Cooper’s ligament.
K41.90 Unilateral femoral hernia, without obstruction or gangrene, not specified as recurrent
The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. If this path is enlarged, it may allow abdominal contents to protrude into the canal. Femoral hernias are particularly at risk of becoming irreducible and strangulated.
Example 2: A 42-year-old female patient presents with a gangrenous Meckel’s diverticulum in a strangulated umbilical hernia sac, and is treated by dissection of diverticulomesenteric bands and diverticulectomy.
K42.0 Umbilical hernia with obstruction, without gangrene
Q43.0 Meckel’s diverticulum (displaced) (hypertrophic)
Umbilical hernias often are noted at birth as a protrusion at the bellybutton. This is caused when an opening in the abdominal wall, which normally closes before birth, doesn’t close completely. If small, this type of hernia may close by age 2. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall.
Example 3: Susan noticed a bulge in her abdominal wall. She indicates the bulge appears to expand under increased abdominal pressure, such as when she coughs or lifts a heavy object. The physician diagnoses her with ventral hernia.
K43.9 Ventral hernia without obstruction or gangrene

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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