acute blood loss anemia
MD has beautiful documentation:acute upper GI bleed, acute gastric ulcer and anemia d/t GI bleeding. My question is: does he have to document "anemia d/t acute blood loss"? I was told he does and then I listened to an ACDIS conference tape and it was stated that it doesn't have to be word for word. As long as the bleed was documented and that it was acute would be sufficient. Does anyone have any comments regarding this? Thank you.
Comments
Anemia
Blood loss
Acute
Or in the encoder:
Bleeding
GI
Ulcer
acute
blood loss anemia?
Yes - acute
I would ask for the specificity of acute blood loss anemia.
Charlene
anemia due to GI bleeding. The two have been linked.
Karen Beal, RN, BSN, CCRN
Clinical Documentation Improvement Specialist
Huntington Hospital
100 W. California Blvd.
Pasadena, CA 91109
626-397-2024
Fax 626-397-2904
karen.beal@huntingtonhospital.com
Malinda
If the physician clearly documents the anemia is due to acute blood loss,
code 285.1 Acute posthemorrhagic anemia should be assigned. Anemia due to
chronic blood loss is coded to 280.0 Secondary to blood loss (chronic).
The physician should always be queried if there is a lack of sufficient
documentation. Never assume cause and effect relationship.
Stacy Vaughn, RHIT, CCS
Data Support Specialist/DRG Assurance
Aurora Baycare Medical Center
2845 Greenbrier Rd
Green Bay, WI 54311
Phone: (920) 288-8655
Fax: (920) 288-3052
ABLA (acute blood loss anemia); or
Acute anemia d/t blood loss; or
Anemia d/t acute blood loss
We just make sure the word "acute" is documented in relationship to the anemia/blood loss
The documentation is sufficient. The MD did say acute upper GI bleed,
acute gastric ulcer and anemia d/t GI bleeding.
I ran this past the coding supervisor. She said you have enough for
acute blood loss anemia. (the blood loss is due to GI bleed, and the
patient has acute UGI bleed and acute gastric ulcer taking care of the
acute portion).
Karen
Chris Lamboley, RN, BSN
Utilization Review Supervisor
Illinois Valley Community Hospital
925 West St.
Peru, Il. 61354
815.780.3294
Fax: 815.780.3640
chris.lamboley@ivch.org
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I'd reference any 'significant' amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN's for this post delivery.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron...
Would you query for acute blood loss?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics....
It is addressing a question for I-10 but the same concept applies to I-9.
[cid:image006.png@01D09924.CE8B6A60]
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
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Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
Laura
That is why I'd review the record to see precisely 'how much' blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Actually, per the UHDDS Definition, treatment is (transfusion) not ‘required’ – although, many would acknowledge that direct treatment of any condition being considered surely strengthens the argument to code said condition.
Conditions may be reported if:
UHDDS Definition
Meets the criteria for a secondary diagnosis if the physician documents the condition, evaluates the condition, or monitors the condition in some fashion that meets the criteria set forth in Coding Clinic such that the condition qualifies in terms of any of the following:
· Clinical Evaluation
· Therapeutic Treatment
· Further evaluation by diagnostic studies, procedures or consultation
· Extended LOS
· Increased nursing care and/or other monitoring
Clinical evaluation means the medical staff is aware of the condition and is evaluating it in terms of evaluation, testing, consultations, and clinical observation of the patient’s condition and/or the existence of the condition affect the types or choices of treatment rendered to the patient.
A physical examination and a history is a ‘routine’ part of every hospital admission. The mere existence of any condition does not mean the condition is always reportable.
Per Faye Brown, 2006, “Codes should not be assigned for conditions that do not meet UHDDS criteria for reporting. For example, diagnostic reports often mention such conditions such as hiatal hernia, atelectasis, and right bundle branch block with no further mention to indicate any relevance to the care given. Assigning a code is inappropriate for reporting purposes unless the physician provides documentation to support the condition’s significance for the episode of care”
The mention of mild or asymptomatic MVP, as an example does not “usually” meet the definition of a reportable condition. In addition, some coders feel it is appropriate to report MVP merely because the record may state something such as: “Echo showed mild MVP”. However, this is NOT a diagnostic statement and this practice is contradicted by Coding Clinic.
Some Examples, with Credit to the publication, “Faye Brown”
Example 1: A low potassium level finding treated with intravenous or oral potassium is clinically significant and should be brought to the attention of the physician if no diagnosis has been documented.
Example 2: A hematocrit of 28 %, even though asymptomatic and not treated, may have been evaluated by the physician with serial hematocrit. Because this is outside the range of normal laboratory values and has been further evaluated, it is significant enough to ask the physician whether an associated diagnosis should be documented.
Example 3: A routine preoperative chest X-ray on an elderly patient reveals collapse of the vertebral body. The patient was asymptomatic and no further evaluation or treatment was carried out. This is a common finding in elderly patients and is probably insignificant for this episode.
Example 4: In the absence of a cardiac problem, an isolated electrocardiographic finding of bundle branch block is ordinarily not significant, whereas a finding of a Mobitz II block may have important implications for the patient's care and would warrant asking the physician whether it should be reported for this admission.
Example 5: Incidental findings on X-ray such as asymptomatic hiatal hernia or diverticulosis should not be reported unless further evaluation or treatment is carried out.
Codes from section 790-796, Nonspecific abnormal findings, should be assigned only when the physician has not been able to arrive at a diagnosis based on an abnormal finding, but considers it clinically significant enough to list in the final diagnostic statement.
Example 6: The physician lists an abnormal sedimentation rate, 790.1, on the face sheet and has been unable to make a definitive diagnosis during the hospitalization.
Example 7: An abnormal pap smear of cervix, 795.0, is listed in the final diagnostic statement.
Sources:
http://www.medicinenet.com/mitral_valve_prolapse/page2.htm
http://en.wikipedia.org/wiki/Mitral_valve
Merck Manual, 16th Edition
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Mark
MARK LEBLANC, RN, MBA, CCDS
DIRECTOR CDI SERVICES
952-353-3505
m.leblanc@thewilshiregroup.net
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:09 PM
To: m.leblanc@thewilshiregroup.net
Subject: RE: [cdi_talk] Acute blood loss anemia
My opinion: interqual and milliman are irrevalent for CDI. These books are not diagnostic. They are about medical necessity. So a patient may have ABLA but not need IP admission because it is not severe enough to require transfusion and can be treated and monitored as an outpatient. But this does not mean that a patient who already is an inpatient can’t have ABLA without requiring transfusion.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:08 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
Interqual and Milliman require transfusion of blood products for the diagnosis to certify inpatient treatment for the stay in the hospital.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:59 PM
To: Mary Snook
Subject: RE: [cdi_talk] Acute blood loss anemia
I believe even without PRBC’s you can support ABLA. If the condition is being monitored (repeat labs) and/or the patient is symptomatic (hypotension, tachycardia, etc), I think a query is indicated. I do think you have to be careful to account for dilution/fluid shifts, especially in surgical patients which is why I like to see the hgb a couple days after surgery.
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:37 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
I only query with transfusion of blood products myself. You have to have the correct Intensity of Service.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:52 PM
To: Mary Snook
Subject: Re: [cdi_talk] Acute blood loss anemia
Hi all, I came in late. Was there a transfusion of PRBC?
_____
From: "CDI Talk"
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 12:00:23 PM
Subject: RE:[cdi_talk] Acute blood loss anemia
RE: ABLA:
That is why I’d review the record to see precisely ‘how much’ blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 9:50 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
My 2 cents is I realize the type of anemia should be specified but it looks dilutional. If she had an epidural, she could have had 2 liters of fluid. I wonder if she was on iron before the delivery. I do not query for drop of Hgb 2 gm if patient has had IV fluid.
Laura
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 12:01 PM
To: Ringland, Laura
Subject: RE:[cdi_talk] Acute blood loss anemia
Hi,
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I’d reference any ‘significant’ amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN’s for this post delivery.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron…
Would you query for acute blood loss?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics….
It is addressing a question for I-10 but the same concept applies to I-9.
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 4:08 PM
To: Fisher, Donna L.
Subject: RE: [cdi_talk] Acute blood loss anemia
Interqual and Milliman require transfusion of blood products for the diagnosis to certify inpatient treatment for the stay in the hospital.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:59 PM
To: Mary Snook
Subject: RE: [cdi_talk] Acute blood loss anemia
I believe even without PRBC’s you can support ABLA. If the condition is being monitored (repeat labs) and/or the patient is symptomatic (hypotension, tachycardia, etc), I think a query is indicated. I do think you have to be careful to account for dilution/fluid shifts, especially in surgical patients which is why I like to see the hgb a couple days after surgery.
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:37 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
I only query with transfusion of blood products myself. You have to have the correct Intensity of Service.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:52 PM
To: Mary Snook
Subject: Re: [cdi_talk] Acute blood loss anemia
Hi all, I came in late. Was there a transfusion of PRBC?
________________________________
From: "CDI Talk"
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 12:00:23 PM
Subject: RE:[cdi_talk] Acute blood loss anemia
RE: ABLA:
That is why I’d review the record to see precisely ‘how much’ blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 9:50 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
My 2 cents is I realize the type of anemia should be specified but it looks dilutional. If she had an epidural, she could have had 2 liters of fluid. I wonder if she was on iron before the delivery. I do not query for drop of Hgb 2 gm if patient has had IV fluid.
Laura
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 12:01 PM
To: Ringland, Laura
Subject: RE:[cdi_talk] Acute blood loss anemia
Hi,
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I’d reference any ‘significant’ amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN’s for this post delivery.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron…
Would you query for acute blood loss?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics….
It is addressing a question for I-10 but the same concept applies to I-9.
[cid:image003.png@01D09961.35533F70]
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
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CONFIDENTIALITY NOTICE: This communication and its attachments may contain confidential or privileged information intended solely for the use of the individual or entity to whom it is addressed. If you are not an intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it (or any portion of the contents) or the attachments is strictly prohibited. If you have received this communication in error, please contact the sender and immediately destroy all copies of the communication and attachments. Thank you.
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If any condition is reportable as per the Official Guidelines, it should be coded, regardless.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image002.jpg@01D09948.16F53C90]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:08 PM
To: Evans, Paul
Subject: RE: [cdi_talk] Acute blood loss anemia
Interqual and Milliman require transfusion of blood products for the diagnosis to certify inpatient treatment for the stay in the hospital.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:59 PM
To: Mary Snook
Subject: RE: [cdi_talk] Acute blood loss anemia
I believe even without PRBC’s you can support ABLA. If the condition is being monitored (repeat labs) and/or the patient is symptomatic (hypotension, tachycardia, etc), I think a query is indicated. I do think you have to be careful to account for dilution/fluid shifts, especially in surgical patients which is why I like to see the hgb a couple days after surgery.
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:37 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
I only query with transfusion of blood products myself. You have to have the correct Intensity of Service.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:52 PM
To: Mary Snook
Subject: Re: [cdi_talk] Acute blood loss anemia
Hi all, I came in late. Was there a transfusion of PRBC?
________________________________
From: "CDI Talk"
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 12:00:23 PM
Subject: RE:[cdi_talk] Acute blood loss anemia
RE: ABLA:
That is why I’d review the record to see precisely ‘how much’ blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image002.jpg@01D09948.16F53C90]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 9:50 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
My 2 cents is I realize the type of anemia should be specified but it looks dilutional. If she had an epidural, she could have had 2 liters of fluid. I wonder if she was on iron before the delivery. I do not query for drop of Hgb 2 gm if patient has had IV fluid.
Laura
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 12:01 PM
To: Ringland, Laura
Subject: RE:[cdi_talk] Acute blood loss anemia
Hi,
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I’d reference any ‘significant’ amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image002.jpg@01D09948.16F53C90]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN’s for this post delivery.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron…
Would you query for acute blood loss?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics….
It is addressing a question for I-10 but the same concept applies to I-9.
[cid:image005.png@01D09948.16F53C90]
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
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CONFIDENTIALITY NOTICE: This communication and its attachments may contain confidential or privileged information intended solely for the use of the individual or entity to whom it is addressed. If you are not an intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it (or any portion of the contents) or the attachments is strictly prohibited. If you have received this communication in error, please contact the sender and immediately destroy all copies of the communication and attachments. Thank you.
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Kathleen Benson RN, BSN, CCDS
Supervisor, Clinical Documentation Integrity
UWHealth University of Wisconsin Hospital
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[cid:image004.png@01D0995A.84497F60]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:09 PM
To: Benson Kathleen
Subject: RE: [cdi_talk] Acute blood loss anemia
My opinion: interqual and milliman are irrevalent for CDI. These books are not diagnostic. They are about medical necessity. So a patient may have ABLA but not need IP admission because it is not severe enough to require transfusion and can be treated and monitored as an outpatient. But this does not mean that a patient who already is an inpatient can’t have ABLA without requiring transfusion.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:08 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
Interqual and Milliman require transfusion of blood products for the diagnosis to certify inpatient treatment for the stay in the hospital.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:59 PM
To: Mary Snook
Subject: RE: [cdi_talk] Acute blood loss anemia
I believe even without PRBC’s you can support ABLA. If the condition is being monitored (repeat labs) and/or the patient is symptomatic (hypotension, tachycardia, etc), I think a query is indicated. I do think you have to be careful to account for dilution/fluid shifts, especially in surgical patients which is why I like to see the hgb a couple days after surgery.
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:37 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
I only query with transfusion of blood products myself. You have to have the correct Intensity of Service.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:52 PM
To: Mary Snook
Subject: Re: [cdi_talk] Acute blood loss anemia
Hi all, I came in late. Was there a transfusion of PRBC?
________________________________
From: "CDI Talk"
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 12:00:23 PM
Subject: RE:[cdi_talk] Acute blood loss anemia
RE: ABLA:
That is why I’d review the record to see precisely ‘how much’ blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 9:50 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
My 2 cents is I realize the type of anemia should be specified but it looks dilutional. If she had an epidural, she could have had 2 liters of fluid. I wonder if she was on iron before the delivery. I do not query for drop of Hgb 2 gm if patient has had IV fluid.
Laura
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 12:01 PM
To: Ringland, Laura
Subject: RE:[cdi_talk] Acute blood loss anemia
Hi,
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I’d reference any ‘significant’ amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN’s for this post delivery.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron…
Would you query for acute blood loss?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics….
It is addressing a question for I-10 but the same concept applies to I-9.
[cid:image007.png@01D0995A.84497F60]
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
---
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CONFIDENTIALITY NOTICE: This communication and its attachments may contain confidential or privileged information intended solely for the use of the individual or entity to whom it is addressed. If you are not an intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it (or any portion of the contents) or the attachments is strictly prohibited. If you have received this communication in error, please contact the sender and immediately destroy all copies of the communication and attachments. Thank you.
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Fairfield Medical Center
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Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:09 PM
To: Salinas, Sharon
Subject: RE: [cdi_talk] Acute blood loss anemia
My opinion: interqual and milliman are irrevalent for CDI. These books are not diagnostic. They are about medical necessity. So a patient may have ABLA but not need IP admission because it is not severe enough to require transfusion and can be treated and monitored as an outpatient. But this does not mean that a patient who already is an inpatient can’t have ABLA without requiring transfusion.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:08 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
Interqual and Milliman require transfusion of blood products for the diagnosis to certify inpatient treatment for the stay in the hospital.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 3:59 PM
To: Mary Snook
Subject: RE: [cdi_talk] Acute blood loss anemia
I believe even without PRBC’s you can support ABLA. If the condition is being monitored (repeat labs) and/or the patient is symptomatic (hypotension, tachycardia, etc), I think a query is indicated. I do think you have to be careful to account for dilution/fluid shifts, especially in surgical patients which is why I like to see the hgb a couple days after surgery.
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:37 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
I only query with transfusion of blood products myself. You have to have the correct Intensity of Service.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 2:52 PM
To: Mary Snook
Subject: Re: [cdi_talk] Acute blood loss anemia
Hi all, I came in late. Was there a transfusion of PRBC?
________________________________
From: "CDI Talk"
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 12:00:23 PM
Subject: RE:[cdi_talk] Acute blood loss anemia
RE: ABLA:
That is why I’d review the record to see precisely ‘how much’ blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 9:50 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
My 2 cents is I realize the type of anemia should be specified but it looks dilutional. If she had an epidural, she could have had 2 liters of fluid. I wonder if she was on iron before the delivery. I do not query for drop of Hgb 2 gm if patient has had IV fluid.
Laura
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 12:01 PM
To: Ringland, Laura
Subject: RE:[cdi_talk] Acute blood loss anemia
Hi,
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I’d reference any ‘significant’ amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN’s for this post delivery.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron…
Would you query for acute blood loss?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics….
It is addressing a question for I-10 but the same concept applies to I-9.
[cid:image003.png@01D0994A.DD12F0A0]
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
---
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Copyright 2013
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CONFIDENTIALITY NOTICE: This communication and its attachments may contain confidential or privileged information intended solely for the use of the individual or entity to whom it is addressed. If you are not an intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it (or any portion of the contents) or the attachments is strictly prohibited. If you have received this communication in error, please contact the sender and immediately destroy all copies of the communication and attachments. Thank you.
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Fairfield Medical Center
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----- Original Message -----
From: "CDI Talk"
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 3:33:21 PM
Subject: RE: [cdi_talk] Acute blood loss anemia
Agree!
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 28, 2015 1:09 PM
To: Salinas, Sharon
Subject: RE: [cdi_talk] Acute blood loss anemia
My opinion: interqual and milliman are irrevalent for CDI. These books are not diagnostic. They are about medical necessity. So a patient may have ABLA but not need IP admission because it is not severe enough to require transfusion and can be treated and monitored as an outpatient . But this does not mean that a patient who already is an inpatient can’t have ABLA without requiring transfusion.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 2:08 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
Interqual and Milliman require transfusion of blood products for the diagnosis to certify inpatient treatment for the stay in the hospital.
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 3:59 PM
To: Mary Snook
Subject: RE: [cdi_talk] Acute blood loss anemia
I believe even without PRBC’s you can support ABLA. If the condition is being monitored (repeat labs) and/or the patient is symptomatic (hypotension, tachycardia, etc), I think a query is indicated. I do think you have to be careful to account for dilution/fluid shifts, especially in surgical patients which is why I like to see the hgb a couple days after surgery.
In this particular case, the physician has already identified the patient as having anemia so I am more comfortable querying for specificity of the condition even without a 20% drop. The diagnosis has already been made, you are simply asking for the underlying cause of the condition.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 1:37 PM
To: Kathryn Good
Subject: RE: [cdi_talk] Acute blood loss anemia
I only query with transfusion of blood products myself. You have to have the correct Intensity of Service.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 2:52 PM
To: Mary Snook
Subject: Re: [cdi_talk] Acute blood loss anemia
Hi all, I came in late. Was there a transfusion of PRBC?
From: "CDI Talk" < cdi_talk@hcprotalk.com >
To: gwojo@wowway.com
Sent: Thursday, May 28, 2015 12:00:23 PM
Subject: RE:[cdi_talk] Acute blood loss anemia
RE: ABLA:
That is why I’d review the record to see precisely ‘how much’ blood is documented as lost during the episode of care.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 9:50 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
My 2 cents is I realize the type of anemia should be specified but it looks dilutional. If she had an epidural, she could have had 2 liters of fluid. I wonder if she was on iron before the delivery. I do not query for drop of Hgb 2 gm if patient has had IV fluid.
Laura
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 12:01 PM
To: Ringland, Laura
Subject: RE:[cdi_talk] Acute blood loss anemia
Hi,
If the Docs say anemia, then we would query for type.
If not, then we would query for significance of a drop of 2gm or more.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 8:57 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] Acute blood loss anemia
I’d reference any ‘significant’ amount of blood listed as lost during the procedure in a query.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 8:48 AM
To: Evans, Paul
Subject: RE:[cdi_talk] Acute blood loss anemia
Thank you
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 11:47 AM
To: Slavin, Cindy
Subject: RE:[cdi_talk] Acute blood loss anemia
Yes. I would query for acute blood loss. I had one of our Vascular surgeons tell me that anything 2gm loss or more after should be considered as possibly an acute blood loss. Our coders query our OB/GYN’s for this post delivery.
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 11:41 AM
To: Melissa Windau
Subject: [cdi_talk] Acute blood loss anemia
Patient with hgb 11.7 to 9.5 post delivery..physician writes anemia, patient is being supplemented with PO iron..is discharged with PO iron…
Would you query for acute blood loss?
From: CDI Talk [ mailto:cdi_talk@hcprotalk.com ]
Sent: Thursday, May 28, 2015 11:23 AM
To: Slavin, Cindy
Subject: [cdi_talk] Excisional Debridement (Bovie)
Below is a CC that clearly states the Bovie can be used as a cutting tool for excision. This might help the coder understand the different uses of the Bovie. Coders love Coding Clinics….
It is addressing a question for I-10 but the same concept applies to I-9.
Do you code excisional debridement done with a Bovie to excisional or nonexcisional?
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
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