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How to Document Hernia Using ICD-10 Codes

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Hernia is a common problem that causes a localized bulge in the abdomen or groin. ICD-10 codes used for documenting various types of this disorder are discussed in this article.

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How to Document Hernia Using ICD-10 Codes

  1. 1. www.outsourcestrategies.com 918-221-7769 How to Document Hernia using ICD-10 Codes Hernia is a common problem that causes a localized bulge in the abdomen or groin. ICD-10 codes used for documenting various types of this disorder are discussed in this article.
  2. 2. www.outsourcestrategies.com 918-221-7769 Hernia is a common problem that usually develops when an internal part of the body pushes through an opening in the muscle or surrounding tissue wall. In most cases, this condition involves a very few symptoms and causes a swelling or localized bulge in the abdomen or groin. Documenting this condition correctly requires considering several important aspects. For accurate clinical documentation of this disorder, physicians can opt for medical billing outsourcing services. Generally, most hernias occur within the abdominal cavity, between the chest and the hips. On the other hand, they can also appear in the upper thigh, belly button, and groin areas. This condition is usually caused by a combination of muscle weakness and strain. At times, the muscle weakness may be present at birth, but more often it occurs later in life. In short, anything that causes an increase in abdominal pressure (including obesity, lifting heavy objects, diarrhea or constipation, or persistent coughing or sneezing) can result in hernia. Depending on its specific causes, a hernia can develop quickly or over a long period of time. Hernias aren’t immediately life-threatening, but they don’t go away on their own. Treatment options include corrective surgery - either via an open or keyhole operation, to prevent potentially dangerous complications. Common Hernia Types The most common types of hernia are –  Inguinal hernia - occurs in the inner groin  Ventral - occurs in the general abdominal/ventral wall  Umbilical - occurs at the belly button  Incisional - occurs through an incision or scar in the abdomen  Hiatal - occurs inside the abdomen, along the upper stomach/diaphragm  Femoral hernia - occurs in the upper thigh/outer groin
  3. 3. www.outsourcestrategies.com 918-221-7769 Signs and Symptoms One of the most common symptoms of a hernia is a bulge or lump in the affected area. Other common symptoms include –  Swelling or bulge in the groin or scrotum (the pouch that contains the testicles)  Increased pain or discomfort in the affected area (usually the lower abdomen), especially when bending over, coughing, or lifting  Increase in the bulge size over time  A dull aching sensation  A sense of feeling full or signs of bowel obstruction Diagnosing and Coding Hernia Hernias are usually diagnosed through a detailed physical examination. Physicians may check or feel for a bulge in the abdomen or groin area that gets larger when the patient stands, coughs or strains. If the diagnosis isn’t readily apparent, physicians may conduct various imaging studies/tests such as an abdominal ultrasound, CT scan or MRI scan. If a hernia is relatively small and is not affecting a patient, physicians may recommend watchful waiting. For instance, in children, physicians may try applying manual pressure to reduce the bulge before considering a surgical option. Painful or enlarged hernias require surgery to relieve discomfort and prevent further complications. Surgery involves an open hernia repair and laparoscopic repair. ICD-10 Codes to Use General Surgery medical coding involves using the specific ICD-10 diagnosis codes for reporting hernia on your medical claims. ICD-10-CM codes used to indicate a diagnosis of hernia come in the rangeK40 - K46.
  4. 4. www.outsourcestrategies.com 918-221-7769 K40 - Inguinal hernia  K40.0 - Bilateral inguinal hernia, with obstruction, without gangrene  K40.00 - Bilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent  K40.01 - Bilateral inguinal hernia, with obstruction, without gangrene, recurrent  K40.1 - Bilateral inguinal hernia, with gangrene  K40.10 - Bilateral inguinal hernia, with gangrene, not specified as recurrent  K40.11 - Bilateral inguinal hernia, with gangrene, recurrent  K40.2 - Bilateral inguinal hernia, without obstruction or gangrene  K40.20 - Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent  K40.21 - Bilateral inguinal hernia, without obstruction or gangrene, recurrent  K40.3 - Unilateral inguinal hernia, with obstruction, without gangrene  K40.30 - Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent  K40.31 - Unilateral inguinal hernia, with obstruction, without gangrene, recurrent  K40.4 - Unilateral inguinal hernia, with gangrene  K40.40 - Unilateral inguinal hernia, with gangrene, not specified as recurrent  K40.41 - Unilateral inguinal hernia, with gangrene, recurrent  K40.9 - Unilateral inguinal hernia, without obstruction or gangrene  K40.90 - Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent
  5. 5. www.outsourcestrategies.com 918-221-7769  K40.91 - Unilateral inguinal hernia, without obstruction or gangrene, recurrent K41 - Femoral hernia  K41.0 - Bilateral femoral hernia, with obstruction, without gangrene  K41.00 - Bilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent  K41.01 - Bilateral femoral hernia, with obstruction, without gangrene, recurrent  K41.1 - Bilateral femoral hernia, with gangrene  K41.10 - Bilateral femoral hernia, with gangrene, not specified as recurrent  K41.11 - Bilateral femoral hernia, with gangrene, recurrent  K41.2 - Bilateral femoral hernia, without obstruction or gangrene  K41.20 - Bilateral femoral hernia, without obstruction or gangrene, not specified as recurrent  K41.21 - Bilateral femoral hernia, without obstruction or gangrene, recurrent  K41.3 - Unilateral femoral hernia, with obstruction, without gangrene  K41.30 - Unilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent  K41.31 - Unilateral femoral hernia, with obstruction, without gangrene, recurrent  K41.4 - Unilateral femoral hernia, with gangrene  K41.40 - Unilateral femoral hernia, with gangrene, not specified as recurrent  K41.41 - Unilateral femoral hernia, with gangrene, recurrent  K41.9 - Unilateral femoral hernia, without obstruction or gangrene
  6. 6. www.outsourcestrategies.com 918-221-7769  K41.90 - Unilateral femoral hernia, without obstruction or gangrene, not specified as recurrent  K41.91 - Unilateral femoral hernia, without obstruction or gangrene, recurrent K42 - Umbilical hernia  K42.0 - Umbilical hernia with obstruction, without gangrene  K42.1 - Umbilical hernia with gangrene  K42.9 - Umbilical hernia without obstruction or gangrene K43 - Ventral hernia  K43.0 - Incisional hernia with obstruction, without gangrene  K43.1 - Incisional hernia with gangrene  K43.2 - Incisional hernia without obstruction or gangrene  K43.3 - Parastomal hernia with obstruction, without gangrene  K43.4 - Parastomal hernia with gangrene  K43.5 - Parastomal hernia without obstruction or gangrene  K43.6 - Other and unspecified ventral hernia with obstruction, without gangrene  K43.7 - Other and unspecified ventral hernia with gangrene  K43.9 - Ventral hernia without obstruction or gangrene K44 - Diaphragmatic hernia  K44.0 - Diaphragmatic hernia with obstruction, without gangrene  K44.1 - Diaphragmatic hernia with gangrene  K44.9 - Diaphragmatic hernia without obstruction or gangrene K45 - Other abdominal hernia  K45.0 - Other specified abdominal hernia with obstruction, without gangrene  K45.1 - Other specified abdominal hernia with gangrene
  7. 7. www.outsourcestrategies.com 918-221-7769  K45.8 - Other specified abdominal hernia without obstruction or gangrene K46 - Unspecified abdominal hernia  K46.0 - Unspecified abdominal hernia with obstruction, without gangrene  K46.1 - Unspecified abdominal hernia with gangrene  K46.9 - Unspecified abdominal hernia without obstruction or gangrene Medical coding for different types of hernia can be a tricky process. For accurate and timely medical billing and claims submission, surgical practices can outsource their medical coding tasks to a professional medical billing company that provides the services of AAPC-certified coding specialists. According to reports from Medscape.com, more than 1 million abdominal wall hernia repairs are performed each year in the United States (2017 statistics), with inguinal hernia repairs constituting nearly 770,000 of these cases. Recognizing the early symptoms of hernia helps to mitigate the risk factors associated with this condition. Hernia, if left untreated may grow and become more painful causing severe complications like strangulation. Prevention tips include – quitting the habit of smoking, maintaining a healthy body weight, avoiding straining during bowel movements or urination, and avoiding lifting weights that are too heavy.

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