M54.2 - Cervicalgia

Clinical Definition

Epistaxis refers to acute bleeding from the nose, specifically originating from the nasal mucosa. While often appearing dramatic, most cases are benign and self-limiting, though some may require medical intervention.

Documentation Requirements

• Location/Source

  • Anterior vs posterior bleeding

  • Specific nostril (left, right, or bilateral)

• Acuity

  • Acute, chronic, or recurrent

• Severity

  • Amount of blood loss

  • Need for intervention

• Causation

  • Trauma if applicable

  • Underlying conditions (hypertension, anticoagulation)

  • Environmental factors (dry air, allergies)

Common Synonyms

• Nosebleed

• Nasal hemorrhage

• Bloody nose

• "Nose is bleeding"

Coding Conflicts

Excludes1:

• Post-procedural epistaxis (R04.81)

• Traumatic epistaxis (coded with injury)

Excludes2:

• Bleeding from nasopharynx (R04.0)

• Hemoptysis (R04.2)

Scribing.io Automation

The AI scribe automatically:

• Identifies bleeding descriptors ("bright red," "dark," "clotted")

• Tags anatomical terms ("septum," "Little's area")

• Captures duration and frequency patterns

• Links relevant comorbidities like hypertension or coagulation disorders

• Maps patient-friendly terms to medical terminology