Gastroenterology Coding Alert

Question: A 36-year-old male patient presented with a small lump on one side of the groin area. He experienced some discomfort, though minimal. The gastroenterologist did a full physical exam and wrote down that the lump appears larger when the patient coughs. They diagnose the patient with a hernia on one side of the body. How do I code this?

Kansas Subscriber

Answer: The most likely code for this is K40.90 (Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent). However, you will want to query the provider to be sure. Here’s why.

Hernias often present with symptoms alongside the lump, but often do not. The physical exam, including the physician’s impressions, should be detailed enough for you to select an accurate diagnosis code. However, in this case, the physician did not specify which type of hernia this was. Generally, only two types that show up in the groin area, or around the inguinal ligament: inguinal and femoral hernias. Inguinal hernias are the more common of the two, but femoral hernias are considerably more dangerous and sometimes require emergency surgery. (source: https:// generalsurgery.ucsf.edu/ conditions--procedures/femoral-(thigh)- hernia.aspx). You’d report femoral hernias from the K41 category.

Because the notes and diagnosis are not specific — both possible hernia types can enlarge when the patient coughs, both occur around the same part of the body, and one possible type is considerably more serious than the other — best practice says to check with the physician to be sure before coding the encounter.