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2025 ICD-10-CM code R23.3

Spontaneous ecchymoses. Petechiae.

Code R23.3 should be used when spontaneous ecchymoses or petechiae are the primary presenting symptom and no definitive diagnosis has been established. If a specific underlying cause is identified, the code for the underlying condition should be used instead.

Medical necessity for the use of R23.3 is established when a patient presents with spontaneous ecchymoses or petechiae without any clear explanation. Further investigation is often required to determine the underlying cause and guide appropriate treatment.

Clinicians are responsible for documenting the presence and characteristics of spontaneous ecchymoses and petechiae, including size, location, and associated symptoms. They may need to order further investigations to identify underlying causes and provide appropriate management.

In simple words: Spontaneous bruising (ecchymoses) and small red or purple spots on the skin (petechiae) appearing without any apparent injury. This excludes newborn bruising and a condition called purpura.

Spontaneous ecchymoses. Petechiae. Excludes1: ecchymoses of newborn (P54.5) purpura (D69.-)

Example 1: A 70-year-old patient presents with multiple spontaneous ecchymoses on their arms and legs. After ruling out trauma, the physician orders blood tests to evaluate for potential clotting disorders or platelet deficiencies., A 25-year-old patient develops petechiae on their lower extremities after starting a new medication. The clinician considers drug-induced thrombocytopenia as a possible cause and adjusts the medication accordingly., A child presents with spontaneous ecchymoses and petechiae, along with fever and fatigue. The physician suspects an infectious cause and performs tests to rule out conditions like meningococcemia or other severe infections.

Documentation should include a detailed description of the skin findings, including size, location, color, and any associated symptoms. The absence of trauma or other identifiable causes should be noted. Results of any laboratory tests, such as complete blood count or coagulation studies, should also be documented.

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