ED Coding and Reimbursement Alert

Question: Encounter notes indicate that the provider treated a patient with “blood-stained sputum.” I cannot find a diagnosis code that lines up with this phrase. Can you help?

Michigan Subscriber

Answer: The diagnosis code you want for this condition is R04.2 (Hemoptysis). While you won’t find an ICD-10 code that directly tracks to R04.2, “blood-stained sputum” is listed is a synonym for hemoptysis under the R04.2 entry in the ICD-10 code book.

The R04 (Hemorrhage from respiratory passages) code set has several different codes (and alternate terms) to represent different respiratory passages that could experience bleeding. Here’s a look at the R04.- codes and their synonyms, where applicable:

• R04.0 (Epistaxis)

o Hemorrhage from nose

o Nosebleed

• R04.1 (Hemorrhage from throat)
• R04.2

o Blood-stained sputum

o Cough with hemorrhage

• R04.81 (Acute idiopathic pulmonary hemorrhage in infants)

o AIPHI

o Acute idiopathic hemorrhage in infants over 28 days old

• R04.89 (Hemorrhage from other sites in respiratory passages)

o Pulmonary hemorrhage NOS

• R04.9 (Hemorrhage from respiratory passages, unspecified).