Pancytopenia due to chemo

If you have a documentation of pancytopenia s/p chemo, can you assign code 284.11, pancytopenia due to chemo?

Comments

  • From ICD-9 Guidelines:
    18. Documentation of Complications of care
    Code assignment is based on the provider’s documentation of the
    relationship between the condition and the care or procedure. The
    guideline extends to any complications of care, regardless of the
    chapter the code is located in. It is important to note that not all
    conditions that occur during or following medical care or surgery are
    classified as complications. There must be a cause-and-effect
    relationship between the care provided and the condition, and an
    indication in the documentation that it is a complication. Query the
    provider for clarification, if the complication is not clearly
    documented.

    Seems to me that "s/p" does not clearly document a cause and effect
    relationship. Could just as easily indicate a temporal relationship.
    I'd suggest query to confirm.

    Don

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  • Agreed. I don’t think 'S/P' always signifies a cause/effect relationship, similar to 'Post-op'. I'd query. Luckily, this is now simpler because the new query brief allows a simple yes/no query for cases like this.

    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

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