ICD-10 Coding for Small Hiatal Hernia(K44.9)
Complete ICD-10-CM coding and documentation guide for Small Hiatal Hernia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Small Hiatal Hernia
K44-K44.9Primary Range
Diaphragmatic hernia codes
This range includes codes for diaphragmatic hernias, including hiatal hernias without obstruction or gangrene.
Key Information: ICD-10 code for small hiatal hernia
Essential facts and insights about Small Hiatal Hernia
Primary ICD-10-CM Code for small hiatal hernia
Decision Criteria
clinical Criteria
- Diagnosis confirmed by imaging showing <2 cm separation
documentation Criteria
- Documentation must specify 'sliding' and 'without obstruction or gangrene'.
Applicable To
- Sliding hiatal hernia
Excludes
- Congenital hiatus hernia (Q40.1)
Clinical Validation Requirements
- Endoscopy or barium swallow showing <2 cm separation
- No evidence of obstruction or gangrene
Code-Specific Risks
- Confusion with paraesophageal hernia coding
Coding Notes
- Ensure documentation specifies 'sliding' and 'without obstruction or gangrene'.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
GERD without esophagitis
K21.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Small Hiatal Hernia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K44.9.
Impact
Clinical: May lead to incorrect treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.
Mitigation Strategy
Train staff on documentation standards, Use templates with required fields
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use K44.9 only for sliding type I hernias.
Impact
Inadequate documentation of hernia type can lead to audit issues.
Mitigation Strategy
Ensure all clinical documentation specifies hernia type and size.
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 Small Hiatal Hernia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Small Hiatal Hernia
Use these documentation templates to ensure complete and accurate documentation for Small Hiatal Hernia. These templates include all required elements for proper coding and billing.
Gastroenterology Clinic Note
Specialty: GastroenterologyRequired Elements
- Patient symptoms
- Endoscopy findings
- Diagnosis details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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