Hernia is a common problem which causes a localized bulge in the abdomen or groin. The condition occurs when there is a weakness or hole in the peritoneum – the muscular wall that usually keeps abdominal organs in place. This weakness in the peritoneum allows organs and tissues to push through, or herniate, producing a bulge. Generally, a hernia develops between your chest and hips. The condition causes very few symptoms or sometimes no symptoms at all, although in some cases you may notice a swelling or lump in your tummy (abdomen) or groin. The lump may disappear when you lie down, and sometimes it can be pushed back. Coughing or straining may make it reappear. Most hernias aren’t immediately life threatening, but they don’t improve on their own and can lead to severe, life-threatening complications. Medications and self-care measures can help reduce the immediate symptoms to some extent. Physicians, in most cases will recommend surgery to fix a hernia that’s painful or enlarging. As reimbursement rules, regulations, and payer policies are subjected to changes frequently, partnering with an experienced medical billing and coding company is the best option to ensure clean and accurate claims for hernia surgery.
One of the common symptoms associated with the condition is a bulge or painless lump in the affected area. However, the condition may be the cause of serious discomfort and pain, with symptoms often becoming worse when standing, straining or lifting heavy items. Other associated symptoms include sudden, severe pain or discomfort in the affected area (especially when bending over, coughing, or lifting), nausea, vomiting, constipation, a feeling of pressure/heaviness in the abdomen, aburning, gurgling, or aching sensation at the site of the bulge, chest pain, acid reflex and difficulty swallowing.
Types of Hernia
- Inguinal hernia – This is one of the most common types of hernia which mainly affects men. It occurs when the intestines push through a weak spot or tear in the lower abdominal wall, often in the inguinal canal.
- Hiatal hernia – This condition is most common in people over 50 years old. It occurs when part of your stomach protrudes up through the diaphragm into your chest cavity.
- Umbilical hernia – This condition occurs when the intestines bulge through their abdominal wall near the belly button. It is more common among babies below 6 months. This is the only type of hernia that often goes away on its own as the abdominal wall muscles get stronger, typically by the time the child becomes 1 year old.
- Femoral hernia –This type occurs when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh.
- Incisional/ventral hernia – The condition arises when tissue pokes through a surgical wound in your abdomen that hasn’t fully healed.
- Epigastric hernia – It occurs when fatty tissue pokes through your abdomen, between your navel and the lower part of your breastbone (sternum).
- Diaphragmatic hernia – This type of hernia occurs when organs in your abdomen move into your chest through an opening in the diaphragm. This condition can also affect babies if their diaphragm doesn’t develop properly in the womb.
There is no specific cause or reason for a hernia to occur (except the case of incisional hernia that occurs due to a complication of abdominal surgery). They are generally caused by a combination of muscle weakness and strain. The condition occurs more commonly in men than in women and the risks increases with age. Other factors that increase your risk of developing a hernia include family history of the condition, obesity, chronic cough, constipation and conditions like cystic fibrosis, enlarged prostate, peritoneal dialysis, abdominal fluid and undescended testicles.
Diagnosis and Treatment Methods
Hernias are usually diagnosed through a detailed physical examination wherein your physician may feel for a bulge in the abdomen or groin that gets larger when you stand, cough or strain. Diagnostic imaging tests like X-ray, Ultrasound and Endoscopy may be conducted to correctly diagnose the symptoms and determine the exact type of hernia.
Treatment options for this condition depend on the size and type of hernia and the severity of your symptoms. Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications. There are two main types of surgical intervention for hernia –open surgery and laparoscopic operation (keyhole surgery). In the case of open surgery, the surgeon makes an incision and pushes the protruding tissue back into your abdomen. On the other hand, laparoscopic is a less invasive technique where several small incisions are made in your abdomen, thereby allowing the surgeon to use various special instruments to repair the hernia.
General surgery medical coding involves using the specific ICD-10 diagnosis codes, CPT procedure codes, HCPCS codes and MS-DRG codes for reporting hernia on your medical claims.
ICD -10 Codes to Indicate a Diagnosis of Hernia
K40 – Inguinal hernia
- K40.0 – Bilateral inguinal hernia, with obstruction, without gangrene
- K40.1 – Bilateral inguinal hernia, with gangrene
- K40.2 – Bilateral inguinal hernia, without obstruction or gangrene
- K40.3 – Unilateral inguinal hernia, with obstruction, without gangrene
- K40.4 – Unilateral inguinal hernia, with gangrene
- K40.9 – Unilateral inguinal hernia, without obstruction or gangrene
K41 – Femoral hernia
- K41.0 – Bilateral femoral hernia, with obstruction, without gangrene
- K41.1 – Bilateral femoral hernia, with gangrene
- K41.2 – Bilateral femoral hernia, without obstruction or gangrene
- K41.3- Unilateral femoral hernia, with obstruction, without gangrene
- K41.4 – Unilateral femoral hernia, with gangrene
- K41.9 – Unilateral femoral hernia, without obstruction or gangrene
K42 – Umbilical hernia
- K42.0 – Umbilical hernia with obstruction, without gangrene
- K42.1 – Umbilical hernia with gangrene
- K42.9 – Umbilical hernia without obstruction or gangrene
K43 – Ventral hernia
- K43.0 – Incisional hernia with obstruction, without gangrene
- K43.1 – Incisional hernia with gangrene
- K43.2 – Incisional hernia without obstruction or gangrene
- K43.3 – Parastomal hernia with obstruction, without gangrene
- K43.4 – Parastomal hernia with gangrene
- K43.5 – Parastomal hernia without obstruction or gangrene
- K43.6 – Other and unspecified ventral hernia with obstruction, without gangrene
- K43.7 – Other and unspecified ventral hernia with gangrene
- K43.9 – Ventral hernia without obstruction or gangrene
K44 – Diaphragmatic hernia
- K44.0 – Diaphragmatic hernia with obstruction, without gangrene
- K44.1 – Diaphragmatic hernia with gangrene
- K44.9 – Diaphragmatic hernia without obstruction or gangrene
K45 – Other abdominal hernia
- K45.0 – Other specified abdominal hernia with obstruction, without gangrene
- K45.1 – Other specified abdominal hernia with gangrene
- K45.8 – Other specified abdominal hernia without obstruction or gangrene
K46 – Unspecified abdominal hernia
- K46.0 – Unspecified abdominal hernia with obstruction, without gangrene
- K46.1 – Unspecified abdominal hernia with gangrene
- K46.9 – Unspecified abdominal hernia without obstruction or gangrene
CPT Codes
Inguinal Hernia
- 49492 – Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks post conception age, with or without hydrocelectomy; incarcerated or strangulated
- 49495 – Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible
- 49496 – Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated
- 49500 – Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible
- 49501 – Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated
- 49505 – Repair initial inguinal hernia, age 5 years or older; reducible
- 49507 – Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated
- 49520 – Repair recurrent inguinal hernia, any age; reducible
- 49521 – Repair recurrent inguinal hernia, any age; incarcerated or strangulated
- 49525 – Repair inguinal hernia, sliding, any age
- 49650 – Laparoscopy, surgical; repair initial inguinal hernia
- 49651 – Laparoscopy, surgical; repair recurrent inguinal hernia
Hiatal Hernia
- 43332 – Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis
- 43333 – Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis
- 43334 – Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis
- 43335 – Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis
- 43336 – Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis
- 43337 – Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis
Umbilical Hernia
- 49580 – Repair umbilical hernia, younger than age 5 years; reducible
- 49582 – Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated
- 49585 – Repair umbilical hernia, age 5 years or older; reducible
- 49587 – Repair umbilical hernia, age 5 years or older; incarcerated or reducible
Femoral Hernia
- 49550 – Repair initial femoral hernia, any age; reducible
- 49553 – Repair initial femoral hernia, any age; incarcerated or strangulated
- 49555 – Repair recurrent femoral hernia; reducible
- 49557 – Repair recurrent femoral hernia; incarcerated or strangulated
Incisional/Ventral Hernia
- 49560 – Repair initial incisional or ventral hernia; reducible
- 49561 – Repair initial incisional or ventral hernia; incarcerated or strangulated
- 49565 – Repair recurrent incisional or ventral hernia; reducible
- 49566 – Repair recurrent incisional or ventral hernia; incarcerated or strangulated
- +49568 – Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair)
- 49652 – Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible
- 49653 – Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated
- 49654 – Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible
- 49655 – Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated
- 49656 – Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible
- 49657 – Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated
Epigastric Hernia
- 49570 – Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure)
- 49572 – Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated
Diaphragmatic Hernia
- 39501 – Repair, laceration of diaphragm, any approach
- 39503 – Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia
- 39541 – Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic
HCPCS Codes
- C1726 – Catheter, balloon dilatation, non-vascular
- C1781 – Mesh (implantable)
- C9364 – Porcine implant, permacol, per square centimeter
MS-DRG Codes
Repair of Diaphragmatic Hernia (Hiatal Hernia, Paraesophageal Hernia)
- 326 – Stomach, Esophageal and Duodenal Procedures W MCC
- 327 – Stomach, Esophageal and Duodenal Procedures W CC
- 328 – Stomach, Esophageal and Duodenal Procedures W/O CC/MCC
Hernia Repair – Inguinal, Femoral
- 350 – Inguinal and Femoral Hernia Procedures W MCC
- 351 – Inguinal and Femoral Hernia Procedures W CC
- 352 – Inguinal and Femoral Hernia Procedures W/O CC/MCC
Hernia Repair – Other (Epigastric, Incisional/Ventral, Lumbar, Parastomal, Spigelian, Umbilical)
- 353 – Hernia Procedures Except Inguinal and Femoral W MCC
- 354 – Hernia Procedures Except Inguinal and Femoral W CC
- 355 – Hernia Procedures Except Inguinal and Femoral W/O CC/MCC
Integrating positive lifestyle habits can help treat the symptoms of hernia in the long run. These include – making dietary changes, avoiding large or heavy meals, stopping the habit of smoking and doing certain kind of exercises (that help strengthen the muscles around the hernia site) and maintaining a healthy body weight.
Medical billing and coding requires knowledge regarding the right coding modifiers and payer-specific medical billing are essential for correct and on-time reimbursement. With all the complexities involved, the support of a reliable and experienced medical coding service provider can be useful for reporting hernia surgical repair procedure correctly.
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