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2025 ICD-10-CM code K25.4

Chronic or unspecified gastric ulcer with hemorrhage.

Adhere to official ICD-10-CM coding guidelines.Code the specific type and severity of the ulcer if known; otherwise, use the unspecified code.Appropriate additional codes should be used to document associated conditions, complications, or comorbidities.

Modifiers may be applicable depending on the services rendered, such as those indicating the type of procedure (e.g., endoscopic hemostasis) or location of service. Consult the appropriate modifier guidelines.

Medical necessity is established by the presence of a symptomatic chronic gastric ulcer with active hemorrhage.Treatment is needed to control bleeding, prevent complications (e.g., hypovolemic shock), and address the underlying cause of the ulcer.

The clinical responsibility involves diagnosing the gastric ulcer through methods such as endoscopy, managing the hemorrhage (potentially requiring blood transfusions, medication, or surgery), treating the underlying cause of the ulcer (e.g., Helicobacter pylori infection, NSAID use), and monitoring the patient's recovery.

IMPORTANT:Related codes may include those specifying the acuity (acute vs. chronic) and presence of other complications (perforation).

In simple words: This code describes a long-lasting or unclearly defined sore in the stomach that's bleeding. The bleeding can be minor or serious.

This code signifies a chronic or unspecified gastric ulcer complicated by hemorrhage.The ulcer, a lesion in the stomach lining, is characterized by prolonged duration or unspecified chronicity and involves active bleeding.The hemorrhage may range in severity from minor to life-threatening.

Example 1: A 60-year-old male patient presents with melena (black, tarry stool) and epigastric pain. Endoscopy reveals a chronic gastric ulcer with active bleeding.The patient receives blood transfusions and medication to stop the bleeding, followed by treatment for Helicobacter pylori infection., A 45-year-old female patient with a history of NSAID use experiences sudden onset of hematemesis (vomiting blood). Endoscopy confirms a chronic gastric ulcer with significant hemorrhage.The patient undergoes endoscopic hemostasis to control the bleeding., A 70-year-old patient with a history of chronic gastric ulcer presents with worsening epigastric pain and anemia.Endoscopy shows a chronic ulcer with slow, persistent bleeding requiring surgical intervention.

Detailed patient history including medication use (especially NSAIDs), symptoms (pain, nausea, vomiting, melena, hematemesis, anemia), relevant physical examination findings, endoscopic findings (location, size, and characteristics of the ulcer; presence and severity of bleeding), laboratory results (complete blood count, blood type and cross-match if transfusion is needed), and treatment plan (medications, procedures, and response to treatment).

** Consider using additional codes to specify the etiology of the ulcer (e.g., Helicobacter pylori infection, NSAID use), associated complications (e.g., anemia, perforation), and any comorbid conditions.

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