AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 3; Ask the Editor

Gastrointestinal Bleeding Secondary to Gastric Ulcer

A patient presents due to acute gastrointestinal bleed (GI).  An esophagogastroduodenoscopy (EGD) was performed, which showed gastric ulcers as well as portal hypertension.  The physician does not link the bleeding to the ulcer nor is it documented that these conditions are unrelated.  Under the revised “With” guideline, it appears that we may assume a relationship between the gastrointestinal bleed and the ulcer.  How should we report gastric ulcer in a patient with gastrointestinal bleeding? ...

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