R00.1 - Bradycardia, unspecified

Clinical Definition

A hernia occurs when a portion of an organ or fatty tissue bulges through a weak area in the surrounding muscle or connective tissue (fascia). An inguinal hernia specifically presents as a bulge in the groin area where intestine/omentum protrudes through the inguinal canal.

Documentation Requirements

• Laterality

  • Right

  • Left

  • Bilateral

• Acuity

  • Initial encounter

  • Subsequent encounter

  • Sequela

• Status

  • With obstruction (specify if gangrenous)

  • Without obstruction/gangrene

  • Recurrent

• Type

  • Direct

  • Indirect

  • Not specified

Common Synonyms

• Groin hernia

• Rupture

• Sports hernia

• Athletic pubalgia

• "Gut poking through"

Coding Conflicts

Excludes1:

• Hydrocele

• Spermatocele

• Varicocele

Excludes2:

• Femoral hernia

Scribing.io Automation

The AI scribe actively monitors for:

• Location descriptors ("groin", "inguinal area")

• Side-specific terms ("right side", "left groin")

• Complication terms ("incarcerated", "strangulated")

• Physical exam findings ("reducible bulge", "tenderness")

• Prior surgical history related to hernias

These keywords are automatically captured and structured into the appropriate documentation fields to support accurate coding.