ICD-10 Coding for Hiatal Hernia with GERD(K44.9, K21.0)
Complete ICD-10-CM coding and documentation guide for Hiatal Hernia with GERD. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hiatal Hernia with GERD
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K44.9 | Diaphragmatic hernia without obstruction or gangrene | Use when documenting a hiatal hernia without obstruction or gangrene. |
|
| K21.0 | Gastroesophageal reflux disease with esophagitis | Use when GERD is present with esophagitis. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for hiatal hernia with GERD
Essential facts and insights about Hiatal Hernia with GERD
Primary ICD-10-CM Codes for hiatal hernia with gerd
Decision Criteria
clinical Criteria
- Presence of hiatal hernia without obstruction or gangrene
Applicable To
- Hiatal hernia without obstruction
- Sliding hernia without obstruction
Clinical Validation Requirements
- Barium swallow or CT showing herniation above the diaphragm
Code-Specific Risks
- Ensure documentation specifies absence of obstruction or gangrene.
Coding Notes
- Ensure documentation differentiates between acquired and congenital hernias.
K21.0 - Gastroesophageal reflux disease with esophagitis
Use when GERD is present with esophagitis.
Applicable To
- GERD with esophagitis
Clinical Validation Requirements
- Endoscopic evidence of esophagitis
Coding Notes
Document endoscopic findings to support esophagitis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Heartburn
R12Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hiatal Hernia with GERD to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K44.9.
Impact
Clinical: Inaccurate treatment planning, Regulatory: Potential audit issues, Financial: Claim denials for lack of specificity
Mitigation Strategy
Ensure endoscopy reports are reviewed, Train staff on documentation requirements
Impact
Reimbursement: May lead to claim denials if not properly documented., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation of patient condition.
Mitigation Strategy
Ensure documentation explicitly states the absence of obstruction or gangrene.
Impact
Using unspecified codes without supporting documentation.
Mitigation Strategy
Ensure detailed documentation of hernia characteristics.
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 Hiatal Hernia with GERD, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hiatal Hernia with GERD
Use these documentation templates to ensure complete and accurate documentation for Hiatal Hernia with GERD. These templates include all required elements for proper coding and billing.
GERD with hiatal hernia
Specialty: GastroenterologyRequired Elements
- Patient history
- Endoscopy results
- Imaging findings
- Treatment response
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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