Neurology & Pain Management Coding Alert

Question: Our provider recently mentioned “easy bruising” in his clinical notes. Is there any specific diagnosis code for easy bruising?

Oklahoma Subscriber

Answer: “Easy bruising” is a symptom, not a diagnosis. You would report the diagnosis code depending upon whether or not the provider identified a cause. If the cause is identified, you should code for the specific disease. However, if the clinician does not document the cause, you should code for the symptoms.

If the clinician documents “easy bruising” with no identifiable cause, then you should report R23.3 (Spontaneous ecchymoses). For example, a patient may suffer from a disease such as a bone marrow disorder that predisposes her to develop bruises, even with a light rap on her feet, which may not bother other patients. This rap could result in “easy bruising” for that particular patient.

Coding tip: An ecchymosis is defined as a bruise that is larger than one centimeter. A bruise that is less than one centimeter, but not less than three millimeters, is called a purpura. A bruise less than three millimeters is called a petechiae. Although R23.3 also applies to petechia, you should not report this code for purpura.