Understand vomiting blood (hematemesis) diagnosis, causes, and treatment. Find information on clinical documentation, medical coding (ICD-10), differential diagnosis, and healthcare guidelines for hematemesis. Learn about related symptoms, upper gastrointestinal bleeding, melena, coffee-ground emesis, and endoscopic findings relevant to vomiting blood. Explore resources for healthcare professionals, including best practices for patient care and accurate medical recordkeeping.
Also known as
Hematemesis
Vomiting of blood, indicating bleeding in the upper digestive tract.
Ulcer of stomach, duodenum
Peptic ulcers can cause bleeding, potentially leading to bloody vomit.
Hemorrhage, unspecified
General category for bleeding, including vomiting blood if cause is unknown.
Peritonitis, other inflammations
Severe inflammation in the abdomen can cause bleeding and hematemesis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the vomiting blood due to esophageal varices?
Yes
With bleeding?
No
Is it Mallory-Weiss Tear?
When to use each related code
Description |
---|
Vomiting blood (hematemesis) |
Mallory-Weiss tear |
Peptic ulcer disease |
Coding vomiting blood without documenting the cause (e.g., ulcer, Mallory-Weiss) leads to inaccurate DRG assignment and lost revenue.
Incorrectly coding hematemesis (vomiting blood) as melena (black stool) impacts quality reporting and clinical documentation integrity.
Failing to code associated conditions like esophageal varices or cirrhosis with hematemesis can underestimate patient acuity and complexity.
Patient presents with hematemesis, the vomiting of blood, with a chief complaint of (describe color and amount of blood emesis, e.g., bright red blood, coffee-ground emesis approximately 100 mL). Onset of vomiting blood was (onset time, e.g., two hours prior to arrival). Associated symptoms include (list associated symptoms, e.g., nausea, abdominal pain, melena, dizziness, syncope, dyspepsia). Patient denies (list pertinent negatives, e.g., hematochezia, prior episodes of hematemesis, recent NSAID use). Medical history includes (list relevant medical history, e.g., peptic ulcer disease, esophageal varices, cirrhosis, coagulopathy). Surgical history includes (list relevant surgical history, e.g., prior gastric surgery, splenectomy). Current medications include (list current medications, e.g., warfarin, aspirin, NSAIDs). Family history is significant for (list relevant family history, e.g., bleeding disorders, gastrointestinal cancers). Physical examination reveals (document vital signs, e.g., blood pressure 8060 mmHg, heart rate 110 bpm, respiratory rate 20 breathsmin; and relevant physical findings, e.g., pallor, abdominal tenderness, melena on rectal exam). Differential diagnosis includes peptic ulcer bleeding, esophageal varices rupture, Mallory-Weiss tear, gastritis, esophagitis, and malignancy. Initial diagnostic workup includes complete blood count, coagulation studies, comprehensive metabolic panel, and type and screen. Treatment plan includes intravenous fluid resuscitation with normal saline, oxygen therapy, and consultation with gastroenterology for esophagogastroduodenoscopy (EGD) to determine the source of bleeding and administer endoscopic therapy if indicated. Patient condition and treatment response will be closely monitored. Further management will be based on EGD findings and clinical course. ICD-10 code K92.0 (Hematemesis) is considered.