Example of proper physician query (clarification) for patient with anemia

Tip Of The Week, December 15, 2005

Example of proper physician query (clarification) for patient with anemia


By Robert S. Gold, MD


A patient comes in with profuse maroon to bright red blood per rectum, has tachycardia, and is "orthostatic" (which means the pulse rate goes up and the blood pressure goes down with change in position from lying to sitting or from sitting to standing, which is not coded as it's a symptom, not a disease) and the hemoglobin drops from 14 to 8.9. A colonoscopy shows a bleeding diverticulum and the patient is transfused four units of packed cells. The physician only documents "anemia." In this case, it is appropriate to ask the physician to clarify the relationship between the acute bleed and the anemia. 


Use such terminology as:


Please clarify in your progress notes or discharge summary if there is a link between the acute gastrointestinal bleed and the new anemia (hemoglobin drop from 14 to 8.9). Is this anemia of acute blood loss from the diverticulum found on colonoscopy? This will help us to assign a code that will properly reflect the severity and pathogenesis of the patient's anemia.


The physician would benefit/appreciate to learn that his or her "acute" intervention actually has more severity associated with it than "chronic" or unspecified. All of the evidence is there that the condition does exist. The result of the clarification will be accurate reflection of the links between otherwise disconnected conditions.