Blood loss anemia

A key documentation issue is whether patients have lost enough blood to become anemic.

Blood loss anemia is a commonly encountered inpatient condition. It may be classified as acute or chronic. A key requirement for proper documentation of anemia is whether patients have lost enough blood to become anemic or, for those with pre-existing chronic anemia, significantly more anemic. The amount of blood lost is not determinative, only the presence and degree of anemia. The World Health Organization's definitions of anemia, by hemoglobin level, are shown in Table 1.

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Image by Getty Images

Chronic blood loss anemia is of course the result of slow, chronic bleeding. Common sources of bleeding are gastrointestinal, urologic, and gynecologic. Acute blood loss anemia is caused by acute bleeding or hemorrhage from any source, even if it is expected (as with surgery), and often complicates chronic blood loss anemia, resulting in acute-on-chronic blood loss anemia. Acute anemia is commonly gastrointestinal, traumatic, surgical, urologic, gynecologic, obstetrical, retroperitoneal, or nasal in origin.

An important clinical question in the setting of pre-existing chronic blood loss anemia is how much acute blood loss is significant enough to constitute acute-on-chronic blood loss anemia. Given that no specific criteria have been established, clinicians must decide for themselves.

Any of the following would suggest a drop in hemoglobin levels significant enough to elicit clinical concern: transfusion necessary; development of symptoms of anemia not previously present; intense serial monitoring of hemoglobin levels; or a drop in hemoglobin of at least 1.0 to 2.0 g/dL, keeping in mind that any decrease is more significant in a patient with a lower baseline level. For example, a decrease to 9 g/dL from a baseline level of 10 g/dL is not nearly as significant as a drop from 8 g/dL to 7 g/dL.

For example, suppose a 50-year-old former professional football player has knee replacement surgery. His hemoglobin level is 16.2 g/dL before surgery and 13.8 g/dL after surgery. This is not acute blood loss anemia because he did not become anemic, even though the amount of the hemoglobin drop was substantial (2.4 g/dL).

Alternatively, imagine the patient is a 30-year-old mother of three who underwent a transvaginal hysterectomy for prolapsed uterus and menometrorrhagia. Her hemoglobin level is 11.5 g/dL before surgery and 9.0 g/dL after surgery. This may be considered acute blood loss anemia. She was anemic preoperatively but substantially more so afterward due to operative blood loss (2.5 g/dL).

A common complication of blood loss is iron deficiency anemia, if supplemental iron is not prescribed, and this condition is assigned the same code as chronic blood loss anemia. If acute blood loss anemia is caused by hemorrhage, that is also a separate identifiable condition. One might think that blood loss anemia ought to be a self-evident, intrinsic component of hemorrhage, but from a coding perspective, the presence of hemorrhage contributes independently to severity of illness and diagnosis-related group (DRG) assignment.

The distinctions among acute or chronic blood loss anemia, iron deficiency anemia, and hemorrhage are crucial for correct coding and DRG assignment, having an impact on risk adjustment, quality reporting, and reimbursement. Pertinent codes are shown in Table 2. Note that ICD-10-CM has no combination code for acute-on-chronic blood loss anemia, so both codes D62 and D50.0 are assigned.

ICD-10-CM has multiple codes for intra- and postoperative hemorrhage, based on the involved organ systems, all of which are classified as complications/comorbidities (CCs). The simple occurrence of hemorrhage during or following a procedure is considered a complication of care unless specifically stated otherwise by the clinician.

Ask Dr. Pinson

Q: In a patient hospitalized with multiple comorbid conditions, including decompensated alcoholic cirrhosis, hepatocellular carcinoma, and hepatic encephalopathy without coma, is acute hepatic encephalopathy coded? Or should the clinician be queried about the acuity of hepatic encephalopathy?

A: As I understand your question, the patient's alcoholic liver failure is an acute decompensation of chronic hepatic failure and the hepatic encephalopathy is new (acute), not a decompensation of chronic hepatic encephalopathy.

The following codes should be assigned: K70.30 for alcoholic cirrhosis (no acute/chronic distinction); K70.40 for alcoholic liver failure (includes acute and/or chronic) without coma for “decompensated” alcoholic cirrhosis/failure with hepatic encephalopathy; and C22.0 for primary hepatocellular carcinoma.

Q: Is it true that codes for certain conditions as principal diagnosis contain their own intrinsic major complication/comorbidity (MCC)?

A: Yes, a very few “combination” codes. A notable one is pulmonary embolism (PE) with acute cor pulmonale: Diagnosis code I26.09 alone is assigned to DRG 175 (PE with MCC).

Q: What diagnoses would be appropriate to document when a patient comes to the ICU on a ventilator after a lengthy surgery, needing some more time to let the anesthesia wear off?

A: Any diagnosis submitted on a claim must meet the test of clinical validity. According to CMS's Statement of Work for the Recovery Audit Program, clinical validation “involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented” in the medical record.

For patients who are mechanically ventilated for more than several hours following surgery, postprocedural respiratory failure or pulmonary insufficiency is sometimes documented. For these diagnoses to meet the requirements of clinical validity, the patient must have acute pulmonary dysfunction requiring nonroutine measures and/or prolonged respiratory support. Acute hypoxemic respiratory failure in a patient on a ventilator should be confirmed with a ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) less than 300.

In an uncomplicated, routine, postoperative ventilator setting, the patient's primary problem is usually some degree of depression of the brain's respiratory center (code G93.89) during routine recovery from anesthesia and physiologic stress of surgery. Do not use “ventilator dependence” (Z99.11), as this is reserved for patients who are chronically dependent on a ventilator.