Many organizations are auditing the code assignments on inpatient and outpatient claims to make sure providers are being reimbursed correctly and patients are receiving quality care. One area of scrutiny is the coding of blood loss anemia. Coders preparing for the CCS Prep exam should be aware of the requirements for coding blood loss anemia and the implications of coding it incorrectly.
Anemia is a condition in which there is a reduction in the number of circulating red blood cells, the amount of hemoglobin, or the volume of packed red cells and causes a decrease in the ability of the blood to deliver oxygen to body tissues and organs. Anemia due to blood loss can be classified as either acute or chronic.
Acute blood loss anemia is caused by rapid, massive hemorrhage. Its etiology is usually traumatic. The causes include ruptured aneurysm; intraoperative blood loss or hemorrhage following surgery, bleeding peptic ulcer and ruptured spleen. In acute blood loss anemia check for documentation of faintness, dizziness, sweating, thirst, rapid respirations, rapid pulse, orthostatic hypotension, melena and diaphoresis. In severe cases symptoms include shock possibly leading to death.
In acute blood loss anemia the hemoglobin, hematocrit and red blood cells (RBC) will increase during and immediately following hemorrhage due to vasoconstriction. These test results will decrease several hours after the acute bleed is controlled. The platelet count may also increase within the first few hours.
Chronic blood loss anemia is caused by depleted iron stores and small, pale RBCs. Its etiology is usually chronic occult bleeding. The causes include slow gastrointestinal bleeding, nosebleeds, heavy menstruation, hematuria and hemorrhoids. The gastrointestinal bleeding may be exacerbated by anti-inflammatory medications prescribed to treat another condition.
In chronic blood loss anemia the hemoglobin (less than 8) and hematocrit (less than 28) are decreased, the platelet count is increased in severe cases, blood smear will reveal an increase in pale centers in RBCs, and the total iron-binding capacity (TBIC) is also increased. Stool exam for occult blood should be positive in cases of gastrointestinal bleeding. Urinalysis may also indicate RBCs.
It is essential to correctly identify the type of blood loss anemia because acute and chronic blood loss anemias are assigned different codes in ICD-9-CM.
280.0 Iron Deficiency Anemia Secondary to Blood Loss (chronic)
285.1 Acute Posthemorrhagic Anemia (anemia due to acute blood loss)
Do not assign a code for blood loss anemia based on abnormal laboratory reports alone. There must be physician documentation in the medical record indicating that the patient has either acute or chronic blood loss anemia. If the medical record documentation is not specific as to whether the blood loss is acute or chronic, query the physician. Even if a patient presents with a history of a recent blood loss with resultant anemia, the coder cannot assume the anemia is due to blood loss without physician documentation supporting the relationship of these two conditions. Never assume a cause and effect relationship.
Blood loss anemia after surgery presents a number of coding challenges. Because acute blood loss anemia may follow surgery, the coder should never assume this is a postoperative complication. Some surgical procedures have anticipated high blood loss. If the physician documents this is the case, the correct code assignment is 285.1. The physician must document that acute blood loss anemia is a complication of surgery in order to assign code 998.11, Hemorrhage complicating a procedure along with the code for acute blood loss anemia, 285.1. When the physician's documentation only states "postoperative anemia" code 285.9, Anemia, unspecified, should be assigned, not one of the blood loss anemia codes. It is important to note that if surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the anemia or for the blood loss.
Under the Medicare MS-DRG methodology code 285.1 is considered a complication/comorbidity (CC) and code 280.0 is not. Therefore incorrect code assignment has potential reimbursement implications. It is also important to note that cases with code 285.1, reported as the only CC diagnosis was one of the target areas of the RAC (Recovery Audit Contractors) pilot demonstration project and is still under scrutiny.
Review the following Coding Clinics for more information on coding acute vs. chronic blood loss anemia; 4th Quarter 1993, 2nd Quarter 1992 and 1st Quarter 2007.
Test your knowledge on blood loss anemia with the following quiz:
1. A patient is admitted with Crohn's disease of the colon and has an intestinal resection. After surgery the patient is diagnosed with acute blood loss anemia. Which of the following would be the appropriate diagnosis code(s) selection?
a. 555.1, 998.11, 285.1
b. 555.1, 285.1
c. 555.1, 280.0
d. 555.1, 998.11, 280.0
2. A patient presents with blood loss anemia secondary to GI hemorrhage from bleeding duodenal ulcer. The patient is treated with transfusions and is discharged. Which of the following would be the appropriate diagnosis code(s) selection?
a. 280.0, 532.40
b. 285.1, 532.40
c. 280.0, 532.00
d. 285.1, 532.00
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.
1. b. Code 555.1 is assigned as the principal diagnosis to report the Crohn's disease. Code 285.1 is assigned to report the acute blood loss anemia. Code 998.11 is not assigned in this instance because the physician does not indicate that the acute blood loss anemia is a complication of the procedure. You can query the physician in this instance to find out if in fact the acute blood loss anemia is a postoperative complication.
2. a. 280.0 is assigned because the blood loss anemia is not documented as acute. The ICD-9-CM index is as follows:
blood loss (chronic) 280.0
The blood loss anemia is listed first because it is the reason for admission and was treated. Code 532.40, Duodenal ulcer chronic or unspecified with hemorrhage without mention of obstructions, is assigned to report the GI hemorrhage due to duodenal ulcer. In both instances it may be appropriate to query the physician to determine if the blood loss anemia and the duodenal ulcer are in fact acute.