Suspected GI bleed with negative Endoscopy

katysuegood@gmail.com · February 2014

What is the recommended course of action when you have a patient with a suspected bleed that has endoscopies that shows a gastric ulcer 'with no active bleeding'? I am looking at a patient with alcoholic liver failure that came in very anemic with these findings.
The d/c summery states alcoholic esophagitis, gastritis and 'clean-based gastric ulcer'. But we also have SEVERE anemia with acute blood loss anemia and anemia of chronic disease.
It is my understanding that no hemorrhage will be coded with this documentation but this contradicts the fact that we are saying the patient had severe ABLA and required 4 units of PRBC's and 1 unit of platelets.
We see this quite a bit where we have patients come in with a suspected GI bleed but the endoscopies show 'no stigmata of recent bleeding'. However, the patient is treated as if they still have a bleed. I understand that GI bleeding can start/resolve quickly.

Would you query for the underlying cause of the blood loss? Do nothing and let it go? Other ideas?

Thanks!

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

debra.stewart@halifaxregional.com · February 2014

Katy,
I believe it would go to GI Bleed either way, we usually let it go as that.
Deb
Debra Stewart RN, BSN
Clinical Documentation Specialist
Sentara/Halifax Regional Hospital
South boston, va. 24592
(434)-517-3317 Work
(434)-222-9884 Cell

mark.dominesey · February 2014

This person has liver failure; the cause of the severe anemia is most likely this. Nevertheless, with ABLA already documented, and a "clean ulcer" present in the documentation, a query may help to clarify the source of the bleeding. We know that the "clean ulcer" likely has bled recently, but it would be better for the documentation to state the source of the already documented ABLA.

This is just a suggestion, though I agree a query is not entirely necessary.

Mark

Mark N. Dominesey, MBA, RN, CCDS, CDIP, CHTS-CP
Director, Auditing & CDI Services
Office: 202.489.4662
Fax: 888.661.7790
Mark.Dominesey@TrustHCS.com
www.TrustHCS.com

katysuegood@gmail.com · February 2014

Really? Every time I see this at our facility they do not code a hemorrhage. In this case, the d/c summery does not actually state 'hemorrhage'.
We have:

PROBLEM LIST AT THE TIME OF DISCHARGE:

1. Alcoholic esophagitis, gastritis, and clean-based gastric ulcer.

2. Acute alcoholic hepatitis.

3. Severe microcytic hyperchromic anemia with normal iron stores and low TIBC consistent

with acute blood-loss anemia and anemia of chronic disease.

4. Coagulopathy secondary to acute liver failure

And I agree with the idea that the liver failure is contributing to the anemia. But they are specifically stating repeatedly that it is also blood loss anemia. If we have blood loss anemia, shouldn't we also have a cause?

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

debra.stewart@halifaxregional.com · February 2014

OH well your problem list does change things! Would probably need to query...our physicians will still usually document GI Bleed with acute blood loss anemia, if we indeed treated it...even with a neg. scope for bleeding...but that is not stated in your d/c summary.

Deb

katysuegood@gmail.com · February 2014

That's what I was thinking. Even when they do document 'suspected hemorrhage with no sign of bleeding per endoscopy' or something similar I routinely do not see a hemorrhage coded. Of course, I follow-up on those when I see them but I think our coders really do not like coding a hemorrhage if it is not corroborated by endoscopy. But my understanding is that after you will not see active bleeding but that the cause of admission may still be a GI bleed that is no longer active?

Am I thinking correctly on this one?

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

debra.stewart@halifaxregional.com · February 2014

Yes our coders will go with GI Bleed even without active bleeding, if it was treated as such. So I do think we are on the same thought processes, but the coders would need that documented in the d/c summary to carry GI Bleed. Hope I'm making sense here.
Deb

katysuegood@gmail.com · February 2014

Perfect sense

Thank you!

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

evanspx@sutterhealth.org · February 2014

Consider this Coding Clinic when you review such cases - we all know that 'active bleeding at the time of EGE' is often NO longer seen after active medical intervention when patients are admitted with GI Bleeding. Often, a subsequent endoscopy exam may not demonstrate 'active bleeding - this does not mean that active bleeding was not present at admit, and subsequently controlled and no longer readily visible during the subsequent exam. In some cases, a query would be required.

AHA Coding Clinic(r) for ICD-9-CM, 2Q 1992, Volume 9, Number 2, Page 9

Question:

If the physician lists acute gastritis with bleeding as a final diagnosis, but there is no documentation of bleeding during the hospitalization except a guaiac positive stool, what code(s) should be as-signed? Should we code acute gastritis with hemorrhage or acute gastritis without hemorrhage and code 792.1, Nonspecific abnormal findings in other body substances, stool contents, for the abnormal lab value?

Answer:

Assign the code 535.01, Acute gastritis with hemorrhage, for the gastritis with hemorrhage. Active bleeding does not have to be demonstrated during the hospital stay in order for the physician to clinically diagnose it based on the history and/or physical findings.
Codes for nonspecific abnormal findings (categories 790-796) are assigned only when listed by the physician in the final diagnostic statement and no probable or definitive diagnosis has been deter-mined.

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

evanspx@sutterhealth.org

katysuegood@gmail.com · February 2014

Yes Paul, thank you.
This is what I usually bring to the coders when I see these cases. But unfortunately, I feel like I see them too often and am concerned that we are often not getting the appropriate Pdx.

In fact, I'm pretty sure I have brought this up before, now that I think of it!

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

katysuegood@gmail.com · February 2014

And one more question, sorry...

So if in the final diagnostic statement, you only have a gastric ulcer (or varices, hemorrhoids, etc), but there is no mention of whether there was or was not bleeding, would you then query? What kind of options would you provide?

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

evanspx@sutterhealth.org · February 2014

Dear Physician/NP/PA (or other responsible provider) __________________________:

The diagnosis of (diagnosis) was documented on (Date), but is not consistently noted in subsequent documentation

Please clarify the following:

1. The above diagnosis was present on admission and is now resolved
2. The above diagnosis was present on admission and is still being monitored, evaluated, or treated
3. The above diagnosis was ruled out
4. The above diagnosis is still a likely, suspected, probable diagnosis
5 Other:________________________________________________________________
6. Unable to determine

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

evanspx@sutterhealth.org

evanspx@sutterhealth.org · February 2014

REQUEST FOR CLARIFICATION - SOURCE OF GI BLEEDING

Date:

Dear Physician/NP/PA (or other responsible provider) _DR.

QUERY: Please document your response on the Query Response note type.

IF POSSIBLE PLEASE CLARIFY/ SPECIFY THE POSSIBLE CAUSE OF GI BLEEDING BASED ON THE FOLLOWING DOCUMENTATION AND FINDINGS

On____ documentation in the _ CONSULT_section of the medical record states: " some evidence of GI bleeding"
EGD FINDINGS= -
COLONOSCOPY IMPRESSION

Paul Evans, RHIA, CCDS

Suspected GI bleed with negative Endoscopy

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