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ICD-10 Guide
ICD-10 CodesK26.5

K26.5

Billable

Chronic or unspecified duodenal ulcer with perforation

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 K26.5 is a billable code used to indicate a diagnosis of chronic or unspecified duodenal ulcer with perforation.

Key Diagnostic Point:

Chronic or unspecified duodenal ulcer with perforation is a serious gastrointestinal condition characterized by the formation of an ulcer in the duodenum, which is the first part of the small intestine. This condition typically arises from chronic inflammation due to factors such as Helicobacter pylori infection, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), and excessive alcohol consumption. Clinically, patients may present with severe abdominal pain, nausea, vomiting, and signs of peritonitis if perforation occurs. The anatomy involved includes the duodenum, which connects the stomach to the jejunum, and its perforation can lead to the leakage of intestinal contents into the abdominal cavity, resulting in acute abdominal emergencies. Disease progression can lead to complications such as hemorrhage, sepsis, and peritonitis, necessitating immediate medical intervention. Diagnostic considerations include endoscopy, imaging studies, and laboratory tests to confirm the presence of an ulcer and assess for perforation. Early diagnosis and treatment are crucial to prevent life-threatening complications.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Diagnostic complexity: Requires imaging and endoscopic evaluation to confirm perforation.
  • Treatment complexity: Often necessitates surgical intervention and management of complications.
  • Documentation requirements: Detailed clinical notes and imaging reports are essential.
  • Coding specificity: Requires precise coding to differentiate from other gastrointestinal conditions.

Audit Risk Factors

  • Common coding errors: Misclassification of ulcer type or failure to document perforation.
  • Documentation gaps: Incomplete clinical notes regarding the patient's history and treatment.
  • Billing challenges: Potential denials due to lack of supporting documentation for the severity of the condition.

Specialty Focus

Medical Specialties

Gastroenterology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

General Surgery

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related ICD-10 Codes

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Chronic duodenal ulcers with perforation significantly impact clinical outcomes and healthcare utilization. They are associated with increased morbidity and mortality rates, necessitating emergency interventions and prolonged hospital stays. The condition is prevalent in populations with high rates of NSAID use and H. pylori infections. Quality measures focus on timely diagnosis and treatment to reduce complications and improve patient outcomes. Understanding the epidemiological trends can aid in preventive strategies and resource allocation in healthcare settings.

ICD-9 vs ICD-10

Chronic duodenal ulcers with perforation significantly impact clinical outcomes and healthcare utilization. They are associated with increased morbidity and mortality rates, necessitating emergency interventions and prolonged hospital stays. The condition is prevalent in populations with high rates of NSAID use and H. pylori infections. Quality measures focus on timely diagnosis and treatment to reduce complications and improve patient outcomes. Understanding the epidemiological trends can aid in preventive strategies and resource allocation in healthcare settings.

Reimbursement & Billing Impact

Reimbursement considerations include the severity of the condition and the necessity for surgical intervention, which may involve higher reimbursement rates. Common denials may arise from insufficient documentation or failure to demonstrate medical necessity for procedures performed. Coders should ensure that all relevant clinical information is included in the patient's medical record to support the claim and avoid potential audits.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by K26.5?

K26.5 specifically covers chronic or unspecified duodenal ulcers that have progressed to perforation. This includes cases where the ulcer has not been previously diagnosed or documented as chronic, but has resulted in a perforation requiring urgent medical attention.

When should K26.5 be used instead of related codes?

K26.5 should be used when there is clear evidence of perforation in a chronic or unspecified duodenal ulcer. If the ulcer is present without perforation, K26.4 should be used instead. Documentation must clearly indicate the presence of perforation to justify the use of K26.5.

What documentation supports K26.5?

Documentation supporting K26.5 should include clinical notes detailing the patient's symptoms, diagnostic imaging results showing perforation, endoscopic findings, and any surgical reports if applicable. Comprehensive documentation is crucial to substantiate the diagnosis and treatment provided.