Gastroenterology Coding Alert

Can you find the right diagnosis codes for these different types of hernias?

Gastroenterologists are no strangers to hernias, but with so many diagnosis codes, it can be challenging for coders to find the right ones. Here are three scenarios to help you test your hernia coding know-how.

Code From the K44 Category for Most Hiatal Hernias

Hiatal hernias occur when part of the stomach protrudes up through the diaphragm and into the chest cavity.

Scenario 1: A male, 55-year-old patient complains of persistent acid reflux and chest pain. The patient is obese with a BMI of 40, a smoker, and has a history of gastroesophageal reflux disease (GERD). The patient’s PCP sent copies of X-rays, which show a spot resembling a retrocardiac mass. The gastroenterologist performs an endoscopy for a closer look.

Endoscopy results show a sliding hiatal hernia. Notes don’t indicate any obstruction or gangrene.

Coding: K44.9 (Diaphragmatic hernia without obstruction or gangrene)

“The most common hernia code in our practice is K44.9. It is rare we see a hiatal hernia with obstruction or gangrene,” says Halee Garner, CPC, CPMA, CCA, certified coder for Digestive Health Partners in Asheville, NC. Obstruction or gangrene is not always as clear to a gastroenterologist as it would be to a surgeon performing a repair. ICD-10-CM code K44.9 also covers diaphragmatic hernia not otherwise specified (NOS).

Coding alert: The K44 category has an Excludes1 note instructing you to code to Q79.0 (Congenital diaphragmatic hernia) or Q40.1 (Congenital hiatus hernia), which are conditions often diagnosed even before birth.

Code From the K40 Category for Inguinal Hernias

Inguinal hernias occur when a loop of intestine, or more commonly some fatty tissue from inside the abdominal cavity, protrudes through a weak spot in the lower abdominal wall, often presenting as a bulge in the groin area.

Scenario 2: A male, 35-year-old patient presents with minimal to no discomfort and a small, but detectable, lump in the groin area. The gastroenterologist performs full physical exam and notes that the lump gets bigger when the patient coughs. No imaging is ordered, and the practitioner diagnoses the condition as an inguinal hernia occurring on just one side of the body.

Coding: K40.90 (Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent)

“Sometimes these [inguinal hernias] are symptomatic, sometimes not,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. Acute symptoms are generally a sign of obstruction, which is more serious. In these cases, coding K40.30 (Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent) would be likely. “A coder should see what the physician describes in the physical exam and how it is described in the impression section of the note, and then code accordingly,” he explains.

Coding alert: Inguinal hernias are common, but be on the lookout for language in the documentation about the inguinal ligament or groin area. Sometimes, femoral hernias get mistaken for or miscoded as inguinal hernias because they each present around the inguinal ligament. Femoral hernias are much less common than inguinal hernias, but often require emergency surgery (source: https://generalsurgery.ucsf.edu/ conditions--procedures/femoral-(thigh)-hernia.aspx). You’ll report femoral hernias from the K41 category.

Code From the K43 Category for Incisional Hernias

Incisional or ventral hernias occur when tissue protrudes through an abdominal surgical scar.

Scenario 3: A female, 44-year-old patient four months post gastric bypass surgery presents with a painful red lump at the incision site. Coughing and sneezing makes the lump more pronounced, and the patient is experiencing nausea and vomiting. The gastroenterologist orders a blood test to check for infection and a CT scan to check for obstruction. Results come back indicating an infection and blockage. The practitioner diagnoses an incisional hernia with obstruction.

Coding: K43.0 (Incisional hernia with obstruction, without gangrene)

There are numerous codes in this section, many falling under K43.6 (Other and unspecified ventral hernia with obstruction, without gangrene). Surgeons get a closer view than gastroenterologists, so diagnosis coding for hernias in gastroenterology offices might regularly fall under unspecified categories.

Remember That Notes Are Key to Clinching Accurate Codes

Specificity is a common issue, and when there are so many codes available, such as with hernias, documentation is that much more important. Unspecified codes are often the most appropriate, but practitioners don’t always prioritize writing complete notes.

“This causes more unspecified ICD-10 codes than what’s probably necessary,” explains Garner. Continued education is essential, as well as an open line of communication between the coders and the practitioners.

“Most doctors are willing to learn where their documentation needs more detail. They want to do their job to the best of their abilities,” she said. If ever notes seem contradictory, vague, or otherwise unclear, it’s always better to query the provider than risk incorrect coding and claim denial.