Find comprehensive information on lower gastrointestinal bleeding diagnosis, including clinical documentation, medical coding (ICD-10 codes K92.0, K92.1, K62.5), and healthcare guidance. Learn about symptoms like hematochezia, melena, and occult blood, along with diagnostic procedures such as colonoscopy and angiography. This resource offers essential information for physicians, nurses, and medical coders seeking accurate and efficient documentation and coding for lower GI bleeds. Explore causes, treatment options, and best practices for managing lower gastrointestinal bleeding in clinical settings.
Also known as
Other lower gastrointestinal bleeding
Bleeding from the lower GI tract, excluding causes like diverticula.
Diverticular disease of intestine
Conditions related to intestinal diverticula, a common cause of lower GI bleeding.
Anal and rectal fissures and ulcers
Tears or sores in the anus or rectum, potentially causing bleeding.
Other hemorrhoids
Hemorrhoids, swollen veins in the anus and rectum, can also bleed.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the bleeding site identified?
Yes
Is it from the small intestine?
No
Is it from the lower GI tract?
When to use each related code
| Description |
|---|
| Lower GI bleed |
| Diverticular bleeding |
| Angiodysplasia of colon |
Coding LGIB without specific location (e.g., colon, rectum) leads to inaccurate DRG assignment and lost revenue. CDI crucial for site documentation.
Failing to code underlying cause (e.g., diverticulosis, angiodysplasia) impacts quality metrics and risk adjustment. CDI should query physicians.
Incorrect distinction impacts severity. Auditing ensures coding aligns with documentation describing melena (black stools) vs. hematochezia (bright red blood).
Patient presents with lower gastrointestinal bleeding (LGIB), manifested by hematochezia, rectal bleeding, and melena. Onset of symptoms was [duration] ago. Associated symptoms include [list symptoms e.g., abdominal pain, cramping, nausea, vomiting, dizziness, weakness, fatigue, change in bowel habits]. Patient reports [positive/negative] history of diverticulosis, diverticulitis, inflammatory bowel disease (IBD) including Crohn's disease and ulcerative colitis, colon polyps, colorectal cancer, hemorrhoids, anal fissures, angiodysplasia, and use of nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, or antiplatelet medications. Vital signs include blood pressure [value], heart rate [value], respiratory rate [value], temperature [value], and oxygen saturation [value]. Physical examination reveals [describe findings e.g., abdominal tenderness, distension, guarding, rectal examination findings]. Differential diagnosis includes diverticular bleeding, IBD-related hemorrhage, ischemic colitis, colorectal cancer, hemorrhoids, anal fissures, angiodysplasia, and medication-induced bleeding. Ordered complete blood count (CBC) to assess for anemia, coagulation studies (PT/INR, PTT) to evaluate clotting function, and comprehensive metabolic panel (CMP) for electrolyte imbalances. Further evaluation may include colonoscopy, CT angiography, or nuclear medicine bleeding scan to identify the source of bleeding. Initial management includes intravenous fluid resuscitation with [type of fluid] at [rate] to maintain hemodynamic stability. Patient education provided regarding the importance of bowel rest, dietary modifications, and medication management. Plan to monitor hemoglobin and hematocrit levels, vital signs, and clinical status for signs of ongoing bleeding or hemodynamic instability. Gastroenterology consultation requested. Will consider blood transfusion if clinically indicated. Follow-up scheduled in [timeframe].