Find comprehensive information on large hiatal hernia diagnosis, including clinical documentation requirements, ICD-10-CM codes (K44.9), CPT codes for surgical repair, and best practices for healthcare professionals. Learn about symptoms, diagnostic testing like EGD and barium swallow, treatment options, and post-operative care. This resource covers key aspects of large hiatal hernia management for accurate medical coding and improved patient outcomes.
Also known as
Diaphragmatic hernia without obstruction or gangrene
This code specifies a diaphragmatic hernia, including hiatal hernias, without obstruction or gangrene.
Sliding hiatal hernia
This code designates a sliding hiatal hernia, the most common type.
Paraesophageal hiatal hernia
This code identifies a paraesophageal hiatal hernia, a less common but potentially more serious type.
Diaphragmatic hernia
This code encompasses all types of diaphragmatic hernias, including hiatal hernias.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the hiatal hernia sliding (axial)?
When to use each related code
| Description |
|---|
| Large hiatal hernia |
| Paraesophageal hernia |
| Sliding hiatal hernia |
Coding a large hiatal hernia without specifying sliding or paraesophageal type (K44.9 vs. K44.0/K44.1) leads to inaccurate severity and reimbursement.
GERD is often present with hiatal hernias. Incorrectly coding both separately (K44.9 and K21.0) can lead to overcoding and denials.
Failing to code complications like obstruction, strangulation, or hemorrhage (e.g., K44.011) with the hernia diagnosis understates acuity and resource use.
Patient presents with symptoms suggestive of a large hiatal hernia, including heartburn, regurgitation, chest pain, dysphagia, and shortness of breath. The patient reports experiencing postprandial fullness and nocturnal reflux. Physical examination reveals mild epigastric tenderness without rebound or guarding. Differential diagnosis includes gastroesophageal reflux disease (GERD), esophageal spasm, angina, and peptic ulcer disease. Upper gastrointestinal endoscopy reveals a large hiatal hernia with evidence of esophagitis. The gastroesophageal junction is significantly displaced above the diaphragm. Biopsy results confirm the presence of esophagitis. Barium swallow study confirms the diagnosis of a large hiatal hernia, demonstrating significant herniation of the stomach into the thoracic cavity. Impression: Large type III or IV hiatal hernia. Plan: Conservative management with lifestyle modifications, including dietary changes, weight loss if indicated, and elevation of the head of the bed. Patient education regarding hiatal hernia symptoms, complications, and management strategies. Pharmacological management with proton pump inhibitors (PPIs) for symptom control and esophagitis treatment. Surgical consultation is considered due to the size of the hernia and the presence of persistent symptoms. Surgical options, including laparoscopic Nissen fundoplication, will be discussed with the patient. Follow-up scheduled in four weeks to assess symptom response to therapy and discuss further management. ICD-10 code K44.9 for diaphragmatic hernia without obstruction or gangrene will be used for billing and coding purposes. CPT codes for the procedures performed, such as the endoscopy and barium swallow, will also be included in the billing documentation.