Health Information Management

Q&A: Coding of blood transfusions

CDI Strategies, November 12, 2015

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Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used has to come from the physician in the progress note, or can this particular information be extrapolated from nursing notes, orders, etc.? As far as I can tell, a blood transfusion is usually administered to whatever peripheral IV line/site is available, unless otherwise contraindicated, or a specific physician order directs the patient care team not to.

A: There are a number of procedure codes within ICD-10-PCS that represent procedures performed by staff not considered to be an independent provider. Depending upon the organization, this could be excisional debridements, peripherally inserted central catheter (PICC) line placement, irrigations, dressing changes, physical therapy activities, swallow studies, various radiology procedures, etc.

We have direction from an AHA Coding Clinic® that tells us that we may assign procedure codes based on the documentation of a non-physician professional when the professional provides the specific service. This applies to procedure coding only where there is documentation to substantiate the code. (AHA Coding Clinic® for ICD-10-CM/PCS First Quarter 2014.)

So, in your example of the blood transfusion, if there are appropriate orders to administer a blood transfusion and the nursing documentation supports the assignment of the procedure code, you can certainly assign the code based on the nurse’s documentation.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

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