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Coding hematemesis with documented esophagitis

T

Tharville

Contributor
Messages
16
Good morning,
The ER doctor has documented hematemesis with melena and nausea and vomiting. In the Medical Decision Making he also documents "esophagitis". My question is would you code esophagitis with bleeding since hematemesis is documented and take off the code for hematemesis or esophagitis unspecified and leave the hematemesis coded as is. Seems logical to code esophagitis with bleeding, but again, he specifically does not say with bleeding.

Thank you for your help.
 
I see why you would presume to code esophagitis with bleeding, as many of the GI codes have instructional notes addressing this scenario. K20.xx does not have a coding tip addressing when to assign "with bleeding" codes, therefore, you would not code it unless clearly documented.

Look at K22.1x to see the coding tip I'm referring to. I hope this helps.
 
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