Clarification: Anemia documentation and coding presents communication hazards
CDI Strategies, September 3, 2009
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Q: Is it true that if a physician documents a precipitous drop in hemoglobin/hematocrit (hgb/hct), then the physician can’t document “anemia” anywhere in the chart?
A: ICD-9-CM code 790.0 (Abnormality of red blood cells) contains an excludes note for anemia (other specified types 280.0-285.9), says Adrienne Gmeiner, RN, CCS, clinical documentation specialist with Lawrence (MA) General Hospital. So, if the physician documented an “anemia” that fell into that range of codes in the record, the coder would not also report symptom code 790.01. This code is intended for a patient who comes in with a precipitous drop in their hct without a determined causal diagnosis.
Q: It’s too bad there is an excludes note regarding anemia. Sometimes a patient comes in with a very low hgb/hct that keeps trending downward. For example, the patient has a heme negative guaiac, and the physician writes ‘anemia.’ Many physicians feel uncomfortable with ‘acute blood loss anemia’ terminology as it might negatively impact his or her quality reporting if it’s not an obvious bleed (e.g. GI).
A: The term “acute blood loss anemia” is not a specific term in coding or in physician language, says Robert S. Gold, MD, CEO/founder of DCBA Inc., in Atlanta.
- If the drop in hemoglobin never reaches a level that meets the criteria for anemia, do not ask the physician to document anemia due to acute blood loss from the fractured femur, because it’s not anemia.
- If the hemoglobin does drop low enough to be called anemia but the physician does not treat the patient for it, do not ask anyone to assign a code for it. In general, do not assign a code for a condition that is not treated or followed as it doesn’t meet the UHDDS criteria as a valid secondary diagnosis.
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