Cracking the Code

Coding GI Conditions with Bleeding

Gastrointestinal (GI) bleeding is not a disease but a symptom of a disorder in a person’s digestive tract. There are many possibilities that may cause GI bleeding, including hemorrhoids, peptic ulcers, diverticulosis/diverticulitis, ulcerative colitis, Crohn’s disease, colonic polyps, or gastritis (just to name a few examples). Per ICD-10-CM Official Guidelines for Coding and Reporting Section I.A.15 “With” guideline, it is safe to presume a causal relationship between two conditions when it is linked by the term “with” or “in” when it appears in a code title. In that case, when a provider documents that a patient has one of the previously mentioned conditions (among other conditions) and GI bleeding, then it is appropriate to assume a relationship between the disorder and bleeding. The ONLY time it is not acceptable is when documentation clearly states that the conditions are unrelated or if the physician documents a different cause of the bleeding.



Q: A 65-year-old patient arrived at the hospital with complaints of weakness and fatigue. The patient also complains of GI bleeding over the past few days. The physician performs an EGD to determine the cause of bleeding. In conclusion, the EGD does not provide a specific source of the bleeding; however, gastric ulcers were revealed.
A: K25.4, chronic or unspecified gastric ulcer with hemorrhage
Reference: Coding Clinic 3rd Quarter 2017 pg. 27: Gastrointestinal bleeding secondary to gastric ulcer
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