Find comprehensive information on paraesophageal hernia diagnosis, including clinical documentation, medical coding, ICD-10 codes (K44.9), CPT codes for surgical repair, symptoms, treatment options, and management. Learn about hiatal hernia types, including type II, III, and IV hernias, and explore resources for healthcare professionals, including coding guidelines and best practices for accurate documentation. Understand the difference between sliding hiatal hernia and paraesophageal hernia. This resource provides valuable insights for physicians, coders, and other healthcare providers involved in the diagnosis and care of patients with a paraesophageal hernia.
Also known as
Diaphragmatic hernia
Covers all types of diaphragmatic hernias, including paraesophageal.
Diaphragmatic hernia, unspecified
Used for paraesophageal hernias when a more specific code isn't available.
Hiatal Hernia
While related, these are distinct from, but may occur with, paraesophageal hernia.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the paraesophageal hernia sliding?
Yes
Code K44.9 Diaphragmatic hernia without obstruction or gangrene
No
Is there obstruction?
When to use each related code
| Description |
|---|
| Paraesophageal Hernia |
| Sliding Hiatal Hernia |
| Mixed Hiatal Hernia |
Using unspecified codes (e.g., K44.9) when documentation supports a more specific type like Type II, III, or IV paraesophageal hernia.
Coding symptoms (e.g., heartburn, dysphagia) separately when they are integral to the paraesophageal hernia diagnosis.
Incorrectly coding complications (e.g., obstruction, gangrene) as separate diagnoses when they are inherent to the hernia itself.
Patient presents with complaints consistent with paraesophageal hernia, including symptoms of heartburn, regurgitation, dysphagia, chest pain, and shortness of breath. The patient reports postprandial fullness and occasional nocturnal cough. Physical examination revealed mild epigastric tenderness without rebound. Auscultation of the lungs and heart were unremarkable. Review of systems was otherwise negative. Differential diagnosis includes gastroesophageal reflux disease (GERD), hiatal hernia, esophageal spasm, and angina. An upper gastrointestinal (GI) series with barium swallow was ordered to evaluate for anatomical abnormalities and confirm the diagnosis of paraesophageal hernia, specifically evaluating for herniation of the gastric fundus alongside the esophagus through the esophageal hiatus. The patient's medical history includes hypertension, managed with lisinopril. Surgical consultation was requested to discuss the potential need for paraesophageal hernia repair, considering the patient's symptoms and the risk of complications such as gastric volvulus and strangulation. Patient education provided regarding lifestyle modifications, including dietary adjustments and weight management, to alleviate symptoms. Current Procedural Terminology (CPT) codes and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for paraesophageal hernia diagnosis and management were reviewed and will be documented appropriately for billing and coding purposes. Follow-up scheduled in two weeks to discuss surgical options and monitor symptom progression. The patient was instructed to return to the clinic sooner if symptoms worsen or new symptoms develop.