2025 ICD-10-CM code K28.3
(Active) Effective Date: N/A Digestive System - Diseases of esophagus, stomach and duodenum (K20-K31) Diseases of the digestive system (K00-K95) Feed
Acute gastrojejunal ulcer without hemorrhage or perforation.
Medical necessity must be established for all services related to the diagnosis and treatment of the gastrojejunal ulcer. The documentation should support the need for diagnostic tests, medications, or other interventions based on the patient's symptoms, clinical findings, and the severity of the ulcer.The clinical rationale for the treatment plan should be clearly documented.
Diagnosis and management of the gastrojejunal ulcer falls under gastroenterologists or general surgeons, depending on the need for surgical intervention. Responsibilities include confirming diagnosis, managing pain and related symptoms, preventing complications (bleeding, perforation), and treating the underlying cause of the ulcer (e.g., H. pylori infection, use of NSAIDs).
In simple words: This code indicates an active ulcer in the area where the stomach joins the small intestine.The ulcer is not bleeding or causing a tear.
Acute gastrojejunal ulcer without hemorrhage or perforation. This code specifies an acute ulcer located in the gastrojejunal region, which is the area where the stomach connects to the jejunum (part of the small intestine).It is further specified that the ulcer is not currently presenting with active bleeding (hemorrhage) or a tear in the stomach or intestinal lining (perforation).
Example 1: A patient presents with abdominal pain and is diagnosed with an acute gastrojejunal ulcer without hemorrhage or perforation via endoscopy., A patient with a history of peptic ulcers develops new-onset epigastric pain after starting NSAID therapy. An endoscopy reveals an acute gastrojejunal ulcer, with no signs of bleeding or perforation. , A post-surgical patient with a gastrojejunostomy develops an acute ulcer at the anastomotic site (gastrojejunal junction) without hemorrhage or perforation.
Documentation should include relevant history (e.g., prior ulcer history, medication use, alcohol use), presenting symptoms, physical exam findings, imaging or endoscopic findings confirming the presence, location, and characteristics of the ulcer. Specifically, the absence of hemorrhage and perforation should be explicitly documented.If H. pylori testing is performed, those results should be recorded as well.
- Specialties:Gastroenterology, General Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office