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v1.0.0
ICD-10 Guide
ICD-10 CodesR04.9

R04.9

Hemorrhage from respiratory passages, unspecified

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R04.9 is a billable code used to indicate a diagnosis of hemorrhage from respiratory passages, unspecified.

Key Diagnostic Point:

Hemorrhage from respiratory passages, unspecified (ICD-10 code R04.9) refers to the presence of blood in the respiratory tract, which may manifest as hemoptysis (coughing up blood) or blood-stained sputum. This condition can arise from various underlying causes, including infections, trauma, malignancies, or vascular abnormalities. The clinical presentation can vary widely, from mild blood-streaked sputum to significant bleeding requiring immediate medical intervention. Accurate diagnosis often necessitates a thorough clinical evaluation, including a detailed patient history, physical examination, and potentially imaging studies or bronchoscopy to identify the source of the hemorrhage. Given the broad range of potential etiologies, this code is used when the specific cause of the hemorrhage is not clearly defined or documented, necessitating careful consideration in clinical documentation to ensure appropriate coding and treatment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes
  • Need for thorough clinical documentation
  • Differentiation from other respiratory conditions
  • Potential for acute versus chronic presentations

Audit Risk Factors

  • Insufficient documentation of the cause of hemorrhage
  • Failure to differentiate between types of respiratory bleeding
  • Inconsistent coding practices among providers
  • Lack of follow-up documentation for ongoing cases

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including onset, duration, and characteristics of the bleeding, as well as any associated symptoms.

Common Clinical Scenarios

Patients presenting with chronic cough and intermittent hemoptysis, requiring evaluation for underlying lung disease.

Billing Considerations

Consideration of comorbid conditions such as COPD or malignancy that may contribute to respiratory bleeding.

Emergency Medicine

Documentation Requirements

Acute care documentation must include vital signs, initial assessment findings, and any interventions performed.

Common Clinical Scenarios

Patients presenting with acute hemoptysis following trauma or in the context of a severe respiratory infection.

Billing Considerations

Rapid assessment and intervention are critical; documentation should reflect the urgency of the situation.

Coding Guidelines

Inclusion Criteria

Use R04.9 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when the cause of the hemorrhage is not specified
  • Documentation must support the use of this code, particularly in cases where further investigation is warranted

Exclusion Criteria

Do NOT use R04.9 When
No specific exclusions found.

Related CPT Codes

31500CPT Code

Intubation, endotracheal, emergency

Clinical Scenario

Used in cases of severe respiratory distress due to hemorrhage.

Documentation Requirements

Document the indication for intubation and the patient's condition.

Specialty Considerations

Emergency medicine providers must ensure rapid documentation of the procedure.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding options, but the use of unspecified codes like R04.9 can lead to increased scrutiny during audits. Coders must ensure that documentation supports the use of this code to avoid potential denials.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding options, but the use of unspecified codes like R04.9 can lead to increased scrutiny during audits. Coders must ensure that documentation supports the use of this code to avoid potential denials.

Reimbursement & Billing Impact

reimbursement and compliance.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use R04.9?

Use R04.9 when there is hemorrhage from the respiratory passages, and the specific cause is not documented or known. Ensure that documentation supports the use of this unspecified code.