ICD-10 Coding for Hiatal Hernia(K44.0, K44.1, K44.9)
Complete ICD-10-CM coding and documentation guide for Hiatal Hernia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hiatal Hernia
K44.0-K44.9Primary Range
Diaphragmatic hernia
This range includes codes for hiatal hernia with and without complications such as obstruction or gangrene.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K44.0 | Diaphragmatic hernia with obstruction, without gangrene | Use when there is documented obstruction without gangrene. |
|
| K44.1 | Diaphragmatic hernia with gangrene | Use when gangrene is confirmed intraoperatively. |
|
| K44.9 | Diaphragmatic hernia without obstruction or gangrene | Use when there are no complications like obstruction or gangrene. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for hiatal hernia
Essential facts and insights about Hiatal Hernia
Primary ICD-10-CM Codes for hiatal hernia
Decision Criteria
clinical Criteria
- Presence of obstruction symptoms
Applicable To
- Hiatal hernia with obstruction
Excludes
- Congenital diaphragmatic hernia (Q79.0)
Clinical Validation Requirements
- Documentation of obstruction, such as vomiting or dysphagia
- Endoscopic findings of stricture or obstruction
Code-Specific Risks
- Misclassification if obstruction is not clearly documented
Coding Notes
- Ensure obstruction is clearly documented to avoid misclassification.
K44.1 - Diaphragmatic hernia with gangrene
Use when gangrene is confirmed intraoperatively.
Applicable To
- Hiatal hernia with gangrene
Excludes
- Congenital diaphragmatic hernia (Q79.0)
Clinical Validation Requirements
- Operative confirmation of gangrene or necrosis
- Imaging showing ischemic changes
Coding Notes
Gangrene must be confirmed by surgery or imaging.
K44.9 - Diaphragmatic hernia without obstruction or gangrene
Use when there are no complications like obstruction or gangrene.
Applicable To
- Uncomplicated hiatal hernia
Excludes
- Congenital diaphragmatic hernia (Q79.0)
Clinical Validation Requirements
- Imaging or endoscopy confirming hernia without complications
Coding Notes
Ensure no complications are present to use this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
History of hiatal hernia repair
Z98.89Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Congenital diaphragmatic hernia
Q79.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hiatal Hernia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K44.0.
Impact
Clinical: Leads to incorrect treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use structured templates for documentation, Ensure thorough clinical evaluation
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data recording.
Mitigation Strategy
Verify hernia type through imaging and documentation.
Impact
Risk of coding errors due to unclear documentation of hernia type.
Mitigation Strategy
Use detailed templates and confirmatory imaging.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Hiatal Hernia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hiatal Hernia
Use these documentation templates to ensure complete and accurate documentation for Hiatal Hernia. These templates include all required elements for proper coding and billing.
Operative note for hiatal hernia repair
Specialty: SurgeryRequired Elements
- Hernia type
- Defect size
- Obstruction/gangrene status
- Surgical approach
- Mesh use
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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