Esophageal varices with bleeding

This code signifies the presence of abnormally enlarged veins in the esophagus, specifically when these varices are actively hemorrhaging. This condition is a serious complication of portal hypertension, often secondary to liver cirrhosis, and presents a significant risk of upper gastrointestinal bleeding.

Apply this code when documentation clearly indicates esophageal varices with evidence of active bleeding, such as hematemesis, melena, or a documented endoscopic finding of bleeding varices. This diagnosis is typically made during an endoscopic examination or based on clinical signs and symptoms of acute GI hemorrhage in a patient with known or suspected portal hypertension.

• Always sequence this code as the primary diagnosis when it is the reason for the encounter.
• Do not use this code if the varices are present but not actively bleeding; a different code for esophageal varices without bleeding would be appropriate.
• Ensure documentation specifies "with bleeding" to support the use of this code, distinguishing it from non-bleeding varices.