Is it appropriate to code "expected postoperative blood loss anemia?"
Our CDI program is less than 3 years old, and we now have conflicting directions on the appropriateness of coding the diagnosis "expected postoperative blood loss anemia."
One direction is that to a Coder, the language of expected means "likely to happen, but not a possible or definitive diagnosis," and therefore it is not a codeable verbiage.
Our vendor training and education materials recommended using this verbiage, if the condition was evaluated, monitored, treated, increased LOS, or increased nursing care. Following our vendor training, we made a deliberate decision to use the term expected to ensure acceptance by the surgeons and to reassure them that by adding this diagnosis, it would not be considered a complication code.
I would appreciate any guidance, particularly any official Coding guidelines that you are aware of, that pertain to this verbiage. Thank you, Faye Bakke
Faye Bakke, RN, CCDS
Manager, Clinical Documentation Improvement
Essentia Health
Revenue Services | Third Street Building, M1C10, #78
400 East 3rd Street, Duluth, MN 55805
P: 218-786-2946
Faye.Bakke@EssentiaHealth.org
One direction is that to a Coder, the language of expected means "likely to happen, but not a possible or definitive diagnosis," and therefore it is not a codeable verbiage.
Our vendor training and education materials recommended using this verbiage, if the condition was evaluated, monitored, treated, increased LOS, or increased nursing care. Following our vendor training, we made a deliberate decision to use the term expected to ensure acceptance by the surgeons and to reassure them that by adding this diagnosis, it would not be considered a complication code.
I would appreciate any guidance, particularly any official Coding guidelines that you are aware of, that pertain to this verbiage. Thank you, Faye Bakke
Faye Bakke, RN, CCDS
Manager, Clinical Documentation Improvement
Essentia Health
Revenue Services | Third Street Building, M1C10, #78
400 East 3rd Street, Duluth, MN 55805
P: 218-786-2946
Faye.Bakke@EssentiaHealth.org
Comments
I see this question but no reply. Is this an informal Q&A between all ACDIS members?
There is a visual aid
P. Evans, RHIA