Ulcer of esophagus with bleeding

This code identifies an erosion or open sore in the esophageal lining that is actively bleeding. This ulceration can be caused by various factors, including acid reflux, medication side effects, or infection, and the bleeding can range from occult to overt hemorrhage.

Apply this code when documentation clearly indicates an esophageal ulcer with an associated hemorrhage, regardless of the severity of the bleeding. Supporting documentation should specify both the presence of an esophageal ulcer and evidence of bleeding, such as hematemesis, melena, or endoscopic findings of active oozing or a visible vessel.

• Do not use this code for bleeding esophageal varices; refer to the Excludes2 note for appropriate codes.
• If the cause of the esophageal ulcer is known (e.g., reflux esophagitis), code the underlying condition first, followed by this code.
• Ensure documentation differentiates between an esophageal ulcer with bleeding and other forms of upper gastrointestinal bleeding.