help! were hemorrhaging!
So a while back (1yr or so) the CDI team that I now work with and the physicians and physician advisor got together and came upon some agreements concerning acute blood loss anemia (abla).
The Surgeons said that they would be more comfortable documenting this after a sx (if present), so long as they could state it as:
"expected acute blood loss anemia post-op"
the important term for them to include was "expected"
Today we found out that our coding team has two consultants doing secondary reviews for them.
These consultants are advising the coders to NOT code abla if the surgeon uses the term "exptected."
Does anyone have any experience with this or know of any guidleines etc...?
we've been looking but I thought that I would (query) ya'll
Thank you!!
Axel Olson, RN, CDS
Clinical Documentation Improvement
Essentia Health
Axel.Olson@essentiahealth.org
The Surgeons said that they would be more comfortable documenting this after a sx (if present), so long as they could state it as:
"expected acute blood loss anemia post-op"
the important term for them to include was "expected"
Today we found out that our coding team has two consultants doing secondary reviews for them.
These consultants are advising the coders to NOT code abla if the surgeon uses the term "exptected."
Does anyone have any experience with this or know of any guidleines etc...?
we've been looking but I thought that I would (query) ya'll
Thank you!!
Axel Olson, RN, CDS
Clinical Documentation Improvement
Essentia Health
Axel.Olson@essentiahealth.org
Comments
The surgeons were probably feeling like they wanted to make it crystal clear that the abla was not a complication when they began documenting that way.
From a coding perspective, sometimes that wording can get tricky because if it is so 'expected', is it clinically significant? (ie; an expected post op ileus following gi surgery)
I would say in most cases of abla-it is significant, especially if the patient is symptomatic and/or requiring a blood transfusion, serial h/h's to monitor for stabilization. Not that having a blood transfusion has to be present to code this diagnosis, but it certainly helps. I would argue especially in those cases that just because it may have been expected; you used additional resources during the stay to treat it.
On the contrary, it would not be appropriate to code abla (expected or not) on cases where there is a slight dip in the h/h, no symptoms, and no intervention-that to me is more indicative of 'expected'.
I can see where the consultants are coming from though as the wording implies that everything is okay/and not out of the ordinary-even when it is! It might be beneficial to educate your surgeons going forward that documenting 'acute blood loss anemia' on its own will NOT result in a complication code unless specifically specified as such. I would also point out that regardless of the documentation abla or expected abla post op, the code is the same.
If it made them more comfortable, they could add in their notes, 'no post-op complications' to cover themselves further.
Good luck!
Kerry
Kerry Seekircher, RN, BSN, CCDS, CDIP
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
Thank you for your response
I agree. From what ive been told they educated the physicians to document this way based on some 3M literature reccommending it.
Im not sure why 3M reccommended it besides physician comfort.
I definatley understand why the coders would be squeemish on coding it.
the patients all have mild to moderate drops in H/H but many are just being monitored via serial labs and not recieving transfusions.
However, often there H/H does not even get below 9 or 10.
its a bit of a conundrum and could cause unfortunate misinformation.
Thank you Kerry!
Axel Olson, RN, CDS
Clinical Documentation Improvement
Essentia Health
Axel.Olson@essentiahealth.org
I believe many incorrectly consider the code 285.1 to represent a COMPLICATION, which is not the case. This false belief is one reason the condition may be underreported at some sites, IMO.
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
For what its worth, our coders DO code Expected acute blood loss anemia. I advocate querying when there is still a >20% drop in Hct a couple days after surgery (to account for fluid shifts and such) regardless of whether the patient required anything more than monitoring for this 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
Just to add-serial labs are considered a form of monitoring and if the pt had a significant drop from his/or her baseline h/h; it may be clinically significant.
When making a decision to query on these cases (especially in the absence of tranfusions, etc..), I think-could I defend this in an audit/are the indicators there? If so, you should be fine. If not-proceed with caution: )
Thanks,
Kerry
I would state that those surgical societies should reexamine the classification of acute blood loss anemia as a 'complication' for certain procedures whereby loss of significant amounts of blood is par for the course.
My coding practice is the same as per your statement.
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
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
I agree. I have had the understanding that serial labs are enough to establish a condition as significantly impacting a pt's stay to warrant reporting it.
Im not sure our coders are confident in this when the term "expected" is used d/t these consultants misinformation...
Ive been seeking some good supports online regarding the term "expected" but Ive not found any guidelines etc...
It seems that the consultants are simply expressing an unsupported opinion.
not sure how to go suggesting the "expert" consultants are mis-informed without having something to back it up besides the code book itself.
Thank you everyone!
Just a thought.
Kerry
as Health Grades but as far as CMS and basic MS-DRG billing, why not
just spell it out
Acute blood loss anemia Not a complication of surgery
Acute blood loss anemia a complication of surgery.
No acute blood loss anemia
Other
Unable to determine
Then it's clearly a complication or not. (With exception of ileus
(that is known)per tabular-our facilities determination) a
complication can not be assumed. So why not just put it on black and
white and if they confidently do not believe its a complication they
can just say so...
Thoughts on being that direct?
Ann
procedure thus expected it should not be coded separately.
Which again stating in black and white complication or no complication
allows for it ti be captured. Assuming its a little more than
typical,requiring increased monitoring and intervention. BUT not
being a ding to surgeon. Maybe the are on anticoagulants or anemic to
start with and NOT THE SURGEONS FAULT but due to patients entire
clinical picture.
Ann
VOLUME 9 SECOND QUARTER
NUMBER 2 1992, Page 15
Anemia Following a Surgical Procedure
Question: How do you code anemia which is diagnosed following a surgical procedure
Answer: It is difficult to respond to a question regarding postoperative anemia, since the answer is dependent on the documentation in the medical record. However, the following scenarios should help in deciding which code(s) to use:
If the physician documents postoperative anemia in the medical record, but does not label the condition as a complication, assign code 285.1, Acute posthemorrhagic anemia.
If the physician documents that a complication arose during or resulting from the procedure, such as an abnormal amount of blood loss, code 998.1, Hemorrhage or hematoma complicating a procedure, would be assigned. Code 285.1 may also be assigned.
If surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the blood loss.
If the physician documents anemia in the medical record sometime after the operative episode, but does not state postoperative or complication, query the physician as to whether the anemia can be further specified. If more specific documentation can be obtained, refer to scenarios one and two above. If the anemia is not further specified, code 285.9, Anemia, unspecified, would be assigned.
One should not use blood transfusions as a definitive variable in determining whether or not to code a postoperative anemia as a complication. If the physician describes the patient as having a complication of surgery which is documented as anemia, the anemia can be coded as a complication regardless of whether or not a transfusion was given.
In addition, if there is normal blood loss during an operation, and the physician has not described the patient as having anemia or a complication of surgery, the lack of a blood transfusion reinforces that the blood loss should not be coded.
The above scenarios are strictly based on the documentation in the medical record.
Coding advice on code assignments contained in this issue are effective with discharges April 1, 1992.
VOLUME 24 FIRST QUARTER
NUMBER 1 2007, Page 19
Postoperative Anemia
Question: What is the correct code assignment for postoperative anemia? Coding Clinic Second Quarter 1992, pages 15-16, stated, "If the physician documents postoperative anemia in the medical record, but does not label the condition as a complication, assign code 285.1, Acute posthemorrhagic anemia." Is this advice still valid?
Answer: When postoperative anemia is documented without specification of acute blood loss, code 285.9, Anemia, unspecified, is the default. Code 285.1, Acute posthemorrhagic anemia, should be assigned, when postoperative anemia is due to acute blood loss. Revisions were made to the Alphabetic Index in 2004, which direct the coder in the following manner:
Anemia
postoperative
due to blood loss 285.1
other 285.9
The directives in the ICD-9-CM manual take precedence over advice published in Coding Clinic.
Coding advice or code assignments contained in this issue effective with discharges March 30, 2007.
Paul Evans, RHIA, CCS, CCS-P, CCDS