Find comprehensive information on hiatus hernia, including clinical documentation, medical coding, ICD-10 codes (K44), CPT codes for diagnostic testing and surgical repair, symptoms, treatment options, and healthcare provider resources. Learn about the different types of hiatal hernias, such as sliding hiatal hernia and paraesophageal hernia, along with associated complications and best practices for accurate diagnosis and coding in medical records. This resource provides valuable information for physicians, nurses, coders, and other healthcare professionals involved in the diagnosis and management of hiatus hernia.
Also known as
Diaphragmatic hernia
Covers all types of hernias involving the diaphragm, including hiatus hernias.
Diaphragmatic hernia, unspecified
Used for hiatus hernias when a more specific type isn't documented.
Specific types of hiatus hernia
Includes sliding, paraesophageal, and other specified hiatus hernias.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the hernia sliding (axial)?
Yes
Code K44.9 Hiatal hernia without obstruction or gangrene
No
Is the hernia paraesophageal?
When to use each related code
| Description |
|---|
| Stomach pushes through diaphragm |
| Heartburn, regurgitation |
| Chest pain, difficulty swallowing |
Coding a general hernia code (e.g., K40.9) instead of a specific hiatus hernia code (e.g., K44.9). Impacts reimbursement and data accuracy.
Coding symptoms (e.g., heartburn) instead of the diagnosed hiatus hernia. Leads to underreporting of the condition and inaccurate quality metrics.
Insufficient documentation of hernia type (sliding vs. paraesophageal) and complications. Hinders accurate coding and potential medical necessity reviews.
Patient presents with complaints consistent with hiatus hernia, including heartburn, acid reflux, regurgitation, and chest pain. Symptoms may be exacerbated by bending over, lying down, or eating large meals. The patient reports experiencing dysphagia intermittently. Physical examination reveals epigastric tenderness but is otherwise unremarkable. Differential diagnosis includes gastroesophageal reflux disease (GERD), esophageal spasm, and angina. Diagnosis of hiatal hernia is suspected based on patient symptoms and will be confirmed with upper gastrointestinal endoscopy or barium swallow study. ICD-10 code K44.9 will be utilized for hiatal hernia without obstruction or gangrene. Treatment plan includes lifestyle modifications such as dietary changes, weight loss if applicable, and elevating the head of the bed. Pharmacological management may include antacids, H2 blockers, or proton pump inhibitors (PPIs) to control acid production. Patient education regarding hiatal hernia symptoms, management, and potential complications provided. Follow-up scheduled to assess response to treatment and discuss surgical options if conservative measures prove ineffective. Patient advised to return to clinic if symptoms worsen or new symptoms develop.