Health Information Management

Q&A: Determining the principal diagnosis for hernia with bowel obstruction

HIM-HIPAA Insider, June 15, 2010

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Q: A patient who has had multiple previous abdominal surgeries now presents with a small bowel obstruction. The physician decides to perform surgery, and findings indicate multiple adhesions with an internal hernia with bowel obstruction. The physician also finds that a portion of bowel is infarcted. The physician performs adhesiolysis and resects necrotic bowel. The pathology report notes the presence of necrosis, but the physician did not document any gangrene. It appears that the internal hernia and the adhesions caused the small bowel obstruction. What should we code as the primary diagnosis and secondary diagnosis for this case?

A: The ICD-9-CM Official Guidelines for Coding and Reporting defines the principal diagnosis as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
According to the information you provided, the internal hernia and the adhesions were the reasons for the surgery. Therefore, you should report the code for the internal hernia with obstruction as the principal diagnosis, followed by the code for the adhesions. The hernia is the most likely cause of the necrosis, which is a known result of a strangulated or incarcerated hernia causing obstruction. The adhesions, in turn, made caring for the hernia more complex and serious.
Editor’s note: This Q&A originally appeared in the June 9 issue of Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at

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