Peptic Ulcer Disease Documentation Guide
Erosion of the gastrointestinal mucosa, typically in the stomach or duodenum, caused by acid and pepsin.
ICD-10 Codes: K25.0, K25.3, K25.7, K25.9, K26.0, K26.3, K26.7, K26.9, K27.9, K28.9
Common Symptoms
- Epigastric pain
- Nausea
- Bloating
- Melena or hematemesis
- Early satiety
Key Documentation Elements
- Ulcer location and type (gastric vs duodenal)
- Acute vs chronic presentation
- H. pylori status and treatment
- Endoscopy findings if performed
- PPI therapy and duration
Documentation Challenges
- Specifying ulcer location (gastric vs duodenal)
- Documenting H. pylori testing and eradication status
- Recording hemorrhage or perforation if present
- Capturing NSAID and anticoagulant use history
Billing Considerations
- Site-specific coding (K25 gastric, K26 duodenal, K27 unspecified)
- Complication documentation (hemorrhage, perforation, obstruction)
- Endoscopy procedure coding when performed
Frequently Asked Questions
How are peptic ulcers coded in ICD-10?
Gastric ulcers use K25.x, duodenal ulcers K26.x, with fourth digits specifying acute/chronic and complications (hemorrhage, perforation). Scribeable codes based on your documented endoscopy findings and clinical presentation.
How does Scribeable help with PUD documentation?
Scribeable captures ulcer characteristics, H. pylori testing, medication history, and endoscopy findings from your encounter, ensuring comprehensive GI documentation with accurate complication and site-specific coding.