As we enter 2011, the current health care discussion continues to lie at the forefront of political discourse nationwide. Reimbursement for task work seems destined to fall further.

Although many colleagues consider it an unnecessary intrusion into the true practice of medicine, I believe that describing what we do in greater detail has never been as critical as it is now. If general surgeons improve documentation, they will reap the benefits in dollars.

In September 2009, General Surgery News published my version of an update on hernia coding. Late last year, I also published an article describing the changes that International Classification of Diseases (ICD)-10 will bring (see November 2010 GSN). Now, I offer a detailed look at what to expect for hernia coding with the new ICD-10 format.

The diagnostic ICD-10 codes will change for good on Oct. 1, 2013. As I noted in the November 2010 issue, the reasons for a new system are principally tied to limitations on the current coding format, which are only five digits. ICD-10, however, has seven characters, which will allow for more specificity.

At the risk of sounding like a broken record, specificity is the key to avoiding unrecognized procedures and codes. The specifics included on history and physical, procedure notes and discharge summaries ultimately form the framework for judging the outcomes of physicians and their facilities. General surgeons, with their vast array of procedural options, have a more difficult job mastering code options. Although many surgical specialists typically adopt and use a finite number of procedural codes (think ear, nose and throat or urology), general surgeons have many more to consider. For instance, within the Current Procedural Terminology (CPT) for hernia procedures, approximately 50 different code options exist.

The basic hernia codes reside in the 49xxx series of codes. Diaphragmatic hernia codes, however, are found in different series depending on the site of approach (43xxx or 39xxx). Chapter XI of the ICD-10 covers diseases of the digestive system and resides between codes K00 and K93, with the hernia section falling between K40 and K46.

The seven-character system works as follows: Character 1 for section; 2 for body system; 3 for root operation; 4 for body part; 5 for approach; 6 for device; and 7 for qualifier. A proper code in ICD-10 may contain three, four, five, six or seven characters depending on specificity. The first through fifth are always assigned a character, but the sixth and seventh are assigned “z” if nothing applies to that procedure.

Table. Chapter IX, Hernia Section
Code Hernia Type Subcategory
K40 Inguinal hernia Direct, double, indirect, oblique bubonocele and scrotal hernia
K41 Femoral hernia
K42 Umbilical hernia Includes: Paraumbilical hernia Excludes: Omphalocele hernia
K43 Ventral incisional hernia, Primary hernia Epigastric and incisional hernia
K44 Diaphragmatic hernia Includes: Hiatal, paraesophageal hernia Excludes: Congenital diaphragmatic hernia
K45 Other abdominal hernia Pudendal, lumbar, obturator, retroperitoneal and sciatic hernias
K46 Unspecified abdominal hernia Includes: Enterocele, epiplocele and intraabdominal hernias Excludes: Vaginal enterocele hernia
Source: Centers for Medicare & Medicaid Services

To code for a hernia surgical intervention, for example, the root operation would be “repair.” The fourth character would indicate the body wall, inguinal, diaphragm and so on. The fifth character would specify whether the approach is open, laparoscopic, transthoracic or something else. The sixth may refer to the mesh type used in a hernia repair. The expanded version also includes biologic or synthetic material.

For hernia, all categories follow K4X.0 for obstruction, K4X.1 for gangrene and K4X.2 for no obstruction or gangrene. Inguinal hernia (K40) may be unilateral, bilateral or unspecified with or without obstruction or gangrene. Obstructed hernia may be incarcerated, irreducible or strangulated. Femoral hernia (K41) follows the same subcategories as inguinal. Umbilical hernia is found under K42, whereas ventral incisional and primary hernias are found as K43. The diaphragmatic hernia codes K44 include hiatal and paraesophageal, but exclude congenital diaphragmatic hernia. The K45 section includes more unusual hernias including other abdominal, pudendal, lumbar, obturator, retroperitoneal or sciatic. K46 includes enterocele, epiplocele and intraabdominal hernias, but excludes vaginal enterocele hernia.

Without documenting these specifics correctly, a general surgeon would find uncharacteristically high morbidity compared with his peers who did document properly. For example, let’s say surgeon A codes correctly and has six unilateral nonrecurrent hernias, three incarcerated hernias with obstruction, two hernias with gangrene, five bilateral hernias and two recurrent hernias. The incarcerated, gangrenous, bilateral, recurrent hernias all carry a higher expected morbidity than unspecified versions. Surgeon B, however, documents 16 cases poorly. These cases default to uncomplicated, even though they may be complicated. As a result, surgeon B’s reimbursement and reputation may suffer.

In our busy careers, few surgeons have spent the time needed to master the nuances and become proficient in speaking the language of coders. Thus, translational errors are bound to occur. That is why the ultimate goal should be for general surgeons to become familiar with the ICD-10 codes and thus avoid making errors that may impact themselves and their facility.


Dr. Newman practices general surgery in Gadsden, Ala., and is on the Blue Cross/Blue Shield physician advisory board. He is president of the University of Alabama Caduceus Club, is an active speaker on physician documentation and coding, and is the Chief Medical Officer for ComplyMD. Follow Dr. Newman on his blog at www.complymd.com or reach him by email at Lucian.Newman@ComplyMD.com.