Last month's column discussed the coding of malnutrition, which at the moment is a hot coding compliance topic. This column discusses the coding of coagulopathy, which is another hot coding topic. This is a condition that often confuses coders and is something that a number of organizations are currently auditing for compliance.
Coagulation is a complex process by which the blood forms clots to block and then heal a damaged blood vessel and stops the bleeding so the damage can be repaired. Clotting is a very complicated process that involves the time release clotting factors I to V and VII to XIII to form a fibrin, which is a protein that forms a blood clot.
Coagulation disorders occur when the blood does not form clots properly. A coagulopathy or clotting defect is any condition in which there is a prolonged clotting time and serious bleeding or resulting hemorrhagic disorder. Coagulation defects are assigned to category 286. Fourth digits identify the specific type of coagulation defect.
286.0 Congenital factor VIII disorder (Hemophilia A)
286.1 Congenital factor IX disorder (Hemophilia B)
286.2 Congenital factor XI disorder (Hemophilia C)
286.3 Congenital deficiency of other clotting factors
286.4 von Willebrand's disease
286.5 Hemorrhagic disorder due to intrinsic circulating anticoagulants
286.6 Defibrination syndrome
286.7 Acquired coagulation factor deficiency
286.9 Other and unspecified coagulation defects
Hemophilia is caused by a genetic absence of clotting factors and is characterized by subcutaneous and intramuscular hemorrhage. Blood clotting factors are substances in the blood that help form a clot. When one or more of these clotting factors are missing, there is a higher chance of bleeding. Von Willebrand's disease is the most common of the inherited coagulation defects. It is caused by a deficiency in clotting factor and platelet function.
Report code 286.7, acquired coagulation factor deficiency, when the patient has coagulopathy due to an acquired cause such as liver failure or Vitamin K deficiency. Report code 286.9 for other and unspecified coagulation defects.
In some instances code 286.5, Hemorrhagic disorder due to intrinsic circulating anticoagulants, is being incorrectly assigned to describe patients on anticoagulants. This has been identified as a coding compliance topic.
An intrinsic circulating anticoagulant inhibits or delays the formation of thromboplastin and is a recognized cause of acquired hemorrhagic disorder. Circulating anticoagulants are usually autoantibodies that fight against the normal clotting mechanism and neutralize specific clotting factors. This condition is not caused by a prescribed anticoagulant drug.
Code 286.5 should not be assigned for adverse reactions due to Coumadin or coumadin-induced coagulopathy. Anticoagulant agents such as Coumadin are not circulating anticoagulants.
Patients who are on a prescribed anticoagulant drug to prevent the formation of blood clots may develop bleeding or hemorrhaging. If a hemorrhage develops that is related to an adverse effect of an anticoagulant drug such as Coumadin, code the hemorrhagic condition first followed by E934.2, adverse effect of anticoagulant, and V58.61, long term use of anticoagulant, as additional codes.
It is important to note that it should not be assumed that the adverse effect is drug related unless it is documented by the physician.
The differences in reimbursement between cases admitted with adverse effects of coagulants and a coagulation defect is significant. For example, if a Medicare patient is admitted for treatment of GI bleeding due to anticoagulant use and the principal diagnosis is 578.9, the typical reimbursement is approximately $4,171. But when code 286.5 is assigned as the principal diagnosis, reimbursement increases to approximately $8,081, a $3,910 increase.
Code 790.92, Abnormal coagulation profile, is available to identify abnormal laboratory findings of prolonged bleeding time without the presence of hemorrhage or a coagulation disorder. This code is used for patients on anticoagulation therapy with prolonged PT/PTR (the desired result of such therapy), or who have abnormal coagulation profiles, but no "hemorrhagic disorder" or other symptoms or signs.
Coding professionals should reference the following AHA Coding Clinics as a refresher on this code assignment:
- Third quarter 1990, page 14
- Third quarter 1992, page 15
- Fourth quarter 1993, volume 29, Number 5 1993 page 16
- Third quarter 2004, page 7
- Second quarter Q 2006 page 17
Test your knowledge with the following questions
1: A patient is admitted with atrial fibrillation and is put on Coumadin. The patient develops epistaxis due to Coumadin while in the hospital. At discharge the physician documents atrial fibrillation, coagulopathy, epistaxis and adverse reaction to Coumadin. What is the appropriate diagnosis code assignment(s) for this case?
a. 427.31, 286.5, E934.2
b. 427.31, 286.5, 784.7, E934.2, V58.61
c. 427.31, 286.5, E934.2, V58.61
d. 427.31, 784.7, E934.2
2: A patient on Coumadin therapy is admitted after vomiting blood secondary to gastritis. The patient's gastritis was evaluated and treated. What is the appropriate diagnosis code assignment(s) for this case?
a. 535.51, V58.61
b.578.0, E934.2, V58.61, 535.50
c. 535.51, E934.2, V58.61
d. 286.5, 535.51, V58.61
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, hospital solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
1. d: Code 427.31, Atrial fibrillation, is assigned as the principal diagnosis. Because the epistaxis is identified as an adverse effect of Coumadin codes 784.7, epistaxis, and E934.2, adverse effect of anticoagulant, are assigned as secondary diagnoses. Code 286.5 is not assigned in this instance because there is no hemorrhage disorder and Coumadin is not an intrinsic circulating anticoagulants.
2: a. Assign codes 535.51, Unspecified gastritis and gastroduodenitis with hemorrhage, and V58.61, Long term use of anticoagulant. The vomiting of blood is not identified as an adverse effect of Coumadin therefore code E934.2, adverse effect of anticoagulant, is not assigned. Code 286.5 is also not assigned because the physician did not identify a coagulation disorder. Even if there was an adverse effect of Coumadin it is not an intrinsic circulating anticoagulant.