ABLA internal policies
* I am seeking information from facilities that have established internal policy/procedures/guidelines/decision trees to address coding and/or querying for ABLA (285.1).
* We are attempting to establish such guidelines to assist CDI/Coders with consistency across numerous medical specialties. We are also currently working with Medical Staff to attempt to establish an in-house definition, possibly by specialty, of what ABLA is.
Thank you.
Laura
Laura Reurink, RN-BC, CPC, CIC
Health Information Manager - CDI & Inpatient Reimbursement
Health Information Management
Avera McKennan Hospital
1325 S. Cliff Avenue
Sioux Falls, South Dakota 57105
Phone: (605)-322-8268
Fax: (605)-322-8104
laura.reurink@avera.org
* We are attempting to establish such guidelines to assist CDI/Coders with consistency across numerous medical specialties. We are also currently working with Medical Staff to attempt to establish an in-house definition, possibly by specialty, of what ABLA is.
Thank you.
Laura
Laura Reurink, RN-BC, CPC, CIC
Health Information Manager - CDI & Inpatient Reimbursement
Health Information Management
Avera McKennan Hospital
1325 S. Cliff Avenue
Sioux Falls, South Dakota 57105
Phone: (605)-322-8268
Fax: (605)-322-8104
laura.reurink@avera.org
Comments
Mary A Hosler MSN, RN
Clinical Documentation Specialist
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
When you say 'develop an in-house definition, possibly by specialty' does this mean different specialties would have different definitions and the CDI/Coder would need to refer to that specialties definition prior to querying?
The thing I find difficult is determining when queries should be initiated on surgical patients. For example, practically all open heart patients will meet general criteria for ABLA post-op (2pt drop in Hgb and/or Hgb < 10). However, our CT surgeons are only comfortable documenting it if the anemia is significant to warrant extra concern/monitoring/transfusions. We have accommodated this to an extent and therefore only query on our CT surg patients when the anemia requires more than the 'usual' care associated with a cardiac procedure. I doubt I could get them to agree with a standard that might apply for a GI bleed or something like that.
Does anyone else use different criteria depending on the type of case or am I alone with this issue?
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
Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com
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
We use the following guidelines:
* If the HGB/HCT drops by 2 grams or greater, we then review for additional clinical indicators
o Transfusion?
o Hypotension
o Fatigue/weakness/syncope/bradycardia
o Tachycardia
o Iron replacement therapy
o IF there are no other clinical indicators except for a drop in HGB/HCT, we will wait another day prior to leaving a query.
* One example, I use with the staff is this: if the HGB drops after surgery ( especially ortho surgery since this is a very wet surgery), seek out other indicators. If the drop in HGB is the only indicator and your patient is participating in therapy and has no other indicators as above, we then wait another day prior to querying.
* We do not want to query if the patient has a temporary hemodilution.
* For our patients arriving with a GIBleed, again we look for other indicators in addition to a low HGB/HCT.
o Consider + stool for blood
o + sputum
o Hypotension
o Weakness, syncope, fatigue
o History of use of NSAIDS, anticoagulation therapy or aspirin.
I hope this may help !
Lisa
Lisa Romanello,RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement Specialist
CJW Medical Center
Quality and Compliance
804-228-6527
Thank you for sharing your process!
Kerry
Kerry Seekircher, RN, CCDS
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
(What about those patients that refuse transfusions due to personal choice, but are clearly symptomatic from ABLA and consume nursing time and lab resources as a consequence of the ABLA)?
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: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
If they refuse transfusion and we have quite a few who do, we use the clinical indicators related to the symptoms, i.e. hypotension, fatigue, unwilling or unable to participate in therapy, tachycardia etc.
Thank you
Lisa
various webinars, conferences, etc.
First of all, the baseline hematocrit is where I start. Then I do not
usually query unless there is a 20% drop in hct. This works well for
the already anemic patient coming in with a GIB or for elective/emergent
surgery. I have never felt using hard & fast numbers such as "below hct
30" or a "certain # of points dropped" as criteria for ABLA. If the
patient's baseline hct is, let's say 30.2, the hct would need to be 24
or less to query for ABLA as I have/am describing.
The general rule I use for surgeries is not assessing for ABLA until 3rd
post op day for all open heart surgeries and 2nd post op day for all
other surgeries. This gives time for all the fluid shifts from surgery
& immediate post op to stabilize. The only time I query sooner is if
there is documented hemorrhaging in the OR or immediate post op period.
***Remember there are different H & H normals for males vs females
Examples: 1) Open mitral valve replacement on otherwise healthy 55 year
old female. Baseline hct normal 37.0. POD #1 hct 28.5 (23% drop). Too
soon for query. On POD #3 hct 30.5 (17.5% drop). Will not query for
ABLA because drop less than 20%. I have found the younger healthy
patient can recover quite nicely.
2) Open mitral valve replacement on 75 year old female with some
comorbidities as well. Baseline hct 33.5 (anemic by definition low hct
normal at our hospital for females 34.7). POD #1 hct 24 (28%drop). Too
soon for query. POD #3 hct 26 (22% drop) Will submit query for ABLA.
The same principle is used for general surgery patients and POD #2 lab
values.
My personal response rate for ABLA for all surgeries including all open
hearts (valves/CABG's)is approx 95-97%.
Per our coding auditor, the complication code here is not used unless
the surgeon documents the bleeding/anemia as a complication. We usually
consider that all open hearts and vascular surgeries have expected large
blood losses, also some ortho surgeries. Sometimes I use the word
"expected" in my query choices for these type cases.
If you have any questions, please call or email me directly.
Karen Maritano, RN
Clinical Documentation Specialist
Legacy Health System
Portland, Oregon
503-413-7154
kmaritan@lhs.org
I agree with you, if the pt is symptomatic, a query should be issued, even if no transfusion.
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: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com
I really like the criteria you have set out for post-op patients. I am going to share this with my team
I also wanted to clarify that yes, the complication code (900 series) is not utilized unless the surgeon documents it as a complication. But as sandy brought up, it is used by STS and considered a complication in their system. So while most of our other surgeons have no issue with documenting ABLA our CT surgeons have only wanted to document it in instances where the treatment/monitoring provided was clearly well above the standard.
Thanks for the great information!
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
these are trying to determine the acuteness of the case. So, no, I
would not wait for another 20% drop for the GIB patient. Most of these,
if not all, would have a query written at initial review. Depending on
the admit hematocrit and clinical indicators, I may vary the choices in
my query to add chronic blood loss anemia and acute on chronic blood
loss anemia.
Karen Maritano, RN
Clinical Documentation Specialist
Legacy Health System
Portland, Oregon
503-413-7154
kmaritan@lhs.org
This is our practice also for a patient presenting with a GIBleed. If they present with a low H/H as well as other clinical indicators, we will query from the onset if the admitting history and physical does not identify anemia with specificity.
It is interesting as we have had several admissions for GIBleed with very little drop in their H/H from admission to discharge. However we do monitor these on a daily basis.
Lisa Romanello
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
Thanks!
Roberta Bosanko-Cera MS, CDIP, CCS-P, CPMA, CPC-P, CEMC
AHIMA ICD-10-CM/PCS Training Instructor
Senior Director, ICD-10
Hospital For Special Surgery
535 E 70th Street
New York, NY 10021
bosankor@hss.edu
212-774-2906 Office
Mary L. Snook RN-BC
Clinical Documentation Specialist
Medical Information Services