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ICD-10 Guide
ICD-10 CodesChapter 11: Diseases of the digestive systemK42

K42

Non-billable

Umbilical hernia

Chapter 11:Diseases of the digestive system

BILLABLE STATUSNo
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 K42 is a used to indicate a diagnosis of umbilical hernia.

Key Diagnostic Point:

An umbilical hernia occurs when a portion of the intestine protrudes through an opening in the abdominal muscles near the umbilicus (navel). This condition is most commonly seen in infants but can also occur in adults, particularly those who are overweight or have a history of multiple pregnancies. Clinically, umbilical hernias may present as a soft bulge near the navel that becomes more prominent when the patient coughs, strains, or cries. In adults, symptoms may include discomfort or pain at the site of the hernia, especially during physical activity. The anatomy involved includes the abdominal wall, particularly the rectus abdominis muscle and the peritoneum. Disease progression can lead to complications such as incarceration or strangulation of the herniated tissue, which may require urgent surgical intervention. Diagnostic considerations include physical examination and imaging studies, such as ultrasound or CT scans, to assess the size and contents of the hernia. Treatment typically involves surgical repair, which can be performed via open or laparoscopic techniques.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Moderate, as imaging may be required for confirmation.
  • Treatment complexity: Moderate, with options ranging from watchful waiting to surgical intervention.
  • Documentation requirements: Requires clear documentation of symptoms, physical findings, and treatment plans.
  • Coding specificity: Moderate, as K42 specifically identifies umbilical hernias but may require additional codes for complications.

Audit Risk Factors

  • Common coding errors: Misidentifying the type of hernia or failing to document complications.
  • Documentation gaps: Incomplete records regarding the patient's symptoms and treatment plan.
  • Billing challenges: Potential denials if the necessity for surgery is not well-documented.

Specialty Focus

Medical Specialties

General Surgery

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Gastroenterology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Umbilical hernias are prevalent in both pediatric and adult populations, with a significant impact on healthcare utilization due to the need for surgical repair in symptomatic cases. The condition can lead to complications if left untreated, affecting quality of life and increasing healthcare costs. Understanding the epidemiology of umbilical hernias can inform preventive strategies and improve patient outcomes.

ICD-9 vs ICD-10

Umbilical hernias are prevalent in both pediatric and adult populations, with a significant impact on healthcare utilization due to the need for surgical repair in symptomatic cases. The condition can lead to complications if left untreated, affecting quality of life and increasing healthcare costs. Understanding the epidemiology of umbilical hernias can inform preventive strategies and improve patient outcomes.

Reimbursement & Billing Impact

Reimbursement considerations include the complexity of the procedure and the patient's overall health status. Common denials may arise from inadequate documentation of the hernia's impact on the patient's daily activities or failure to demonstrate medical necessity for surgery. Best practices include ensuring that all relevant clinical notes, imaging studies, and operative reports are complete and accurately reflect the patient's condition and treatment plan.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by K42?

K42 specifically covers umbilical hernias, which may be classified as reducible or incarcerated. It does not cover other types of hernias such as inguinal or femoral hernias.

When should K42 be used instead of related codes?

K42 should be used when the hernia is specifically located at the umbilicus. If the hernia is in another location, such as the groin, then related codes like K40 (inguinal hernia) should be utilized.

What documentation supports K42?

Documentation should include a detailed history of the patient's symptoms, physical examination findings, imaging results if applicable, and the treatment plan, including any surgical interventions.