Sunday, January 3, 2016

Coding for Anemia in OB and GYN Patients: The Documentation Challenge

Coding for Anemia in OB and GYN Patients:  The Documentation Challenge
June 21, 2015

The diagnosis coding for anemia is always difficult, but clear documentation from the providers is rarely found in the medical record or operative notes.  This problem is amplified when coding for anemia in an OB or GYN patient.  Acute blood loss may result in anemia, just as chronic blood loss can result in anemia.  The issue for coders is determining if the blood loss has been documented by the provider as “anemia”.  In addition, anemia is a separately identifiable condition, that can directly affect the patients’ plan of care and coding of the condition. 

The definition of anemia is “a quantitative deficiency of the hemoglobin, often accompanied by a reduced number of red blood cells and causing pallor, weakness, and breathlessness”, but that is not necessarily what is used by clinicians to determine if a patient does or does not have anemia.   Providers rely on the hemoglobin and hematocrit blood test results to give them a clinical picture of the patients’ Hgb (hemoglobin) and HCT (hematocrit).  The lab values for Hgb and HCT differ for men and women.  The values below are considered the “normal limit” upon which an anemia diagnosis would be based.  The Hgb and HCT can be found in the (CBC) Complete Blood Count Test lab results as noted in the table below. 

Hemoglobin
Hematocrit
Women
12 - 16 g/dL
35 – 47%
Men
14 - 18 g/dL
40 - 52%

In ICD-9 there are many types of anemia that are shown in the code-set from category 280.0 – 285.9 and in the D50-D89 section in ICD-10.  However, in ICD-10 the pregnancy anemia code is listed under code O99.0 and in ICD-9 it is listed as 648.23 Maternal Anemia. 

Diseases of The Blood And Blood-Forming Organs 280-289 >
280 Iron deficiency anemias
281 Other deficiency anemias
282 Hereditary hemolytic anemias
283 Acquired hemolytic anemias
284 Aplastic anemia and other bone marrow failure syndromes
285 Other and unspecified anemias
286 Coagulation defects
287 Purpura and other hemorrhagic conditions
288 Diseases of white blood cells
289 Other diseases of blood and blood-forming organs

ICD-9  648.2 Anemia complicating pregnancy childbirth or the puerperium
648.20 Anemia of mother, unspecified as to episode of care or not applicable
648.21 Anemia of mother, delivered, with or without mention of antepartum condition
648.22 Anemia of mother, delivered, with mention of postpartum complication
648.23 Anemia of mother, antepartum condition or complication
648.24 Anemia of mother, postpartum condition or complication

In ICD-10 the anemia codes are held within the codes of D50 – D59.  
D50-D53  Nutritional anemias
D55-D59  Hemolytic anemias
D60-D64  Aplastic and other anemias and other bone marrow failure syndromes
D65-D69  Coagulation defects, purpura and other hemorrhagic conditions
D70-D77  Other disorders of blood and blood-forming organs
D78-D78  Intraoperative and postprocedural complications of the spleen
D80-D89  Certain disorders involving the immune mechanism

The ICD-10 codes for Anemia in pregnancy are found in these codes
O99.0 Anemia complicating pregnancy, childbirth and the puerperium
O99.01 Anemia complicating pregnancy
O99.011 is a specific ICD-10-CM diagnosis code O99.011 …… first trimester
O99.012 is a specific ICD-10-CM diagnosis code O99.012 …… second trimester
O99.013 is a specific ICD-10-CM diagnosis code O99.013 …… third trimester
O99.019 is a specific ICD-10-CM diagnosis code O99.019 …… unspecified trimester
O99.02 is a specific ICD-10-CM diagnosis code O99.02 Anemia complicating childbirth
O99.03 is a specific ICD-10-CM diagnosis code O99.03 Anemia complicating the puerperium


If a patient with acute bleeding (hemorrhage), loses enough blood to become anemic, the diagnosis of acute blood loss anemia is appropriate.  In addition, patients who have a preexisting anemia (chronic or acute) and become more anemic due to bleeding or hemorrhage following surgery or a delivery, it is still classified as a blood loss anemia. Blood loss during surgery and delivery is expected, but not all surgical blood loss causes an anemia, does a hemorrhage necessarily cause an anemia.  Not all anemia diagnoses requires a treatment such as a transfusion. 

Coding Blood loss anemia after surgery can be challenging, as the coder should never assume this is a postoperative complication. Many of the surgeries in OB and GYN are expected to have high blood loss.  If this is the case, then the physician should document this with the correct documentation.  If this is the case, the correct code assignment is 285.1.  If acute blood loss anemia is a complication of surgery , then the documentation should reflect the complication and it would then be correct to assign codes 998.11 and code 285.1. 

 If the physician documentation only states "postoperative anemia", the coder should only code 285.9, Anemia, unspecified.  Again, a coder cannot “assume” that the anemia is a  blood loss anemia.  The most important guideline for a coder to follow is if the physician does not describe the patient as having an anemia, a hemorrhage or a complication of surgery, do not assign any codes for an anemia or blood loss.

In OB and GYN practices these are the most common reasons for an anemia
·         Menstruation causes the loss of red blood cells with the sloughing off of the uterine lining every month, and if there is a heavy blood loss every 28 days, some women are not able to replace it quickly enough, therefore becoming anemic (eg blood loss anemia, not related to a surgery or trauma)

·         Pregnancy increases the risk of iron deficiency anemia because the iron stores have to serve both the increased blood volume for your own body as well as be a source of hemoglobin for the fetus.

·         Post-Operative Hemorrhage is a common reason for an anemia in an OB/GYN patient, however the physician would also need to notate the cause/hemorrhage relationship in the medical record and if the hemorrhage was directly related to a surgery and/or delivery. 

In pregnancy, it is normal to have a mild or mild-persistent anemia. Pregnancy related anemia can be mild, but may convert into a more severe anemia from low iron or vitamin levels.  When coding a symptom code in a pregnant or gynecology patient, they may only discuss symptoms such as “feeling tired/fatigued” or “weak”. If the provider does not specifically state this is an anemia, then anemia should not be coded, or forward a query to the provider to determine correct coding.  (eg symptom code, or anemia code)  If the anemia IS severe but is not treated or evaluated, the “hidden” anemia may increase the risk of a serious complication such as a pre-term delivery, or an antepartum or postpartum hemorrhage. 

There are several types of anemia that can develop in the antepartum period they are
·         Iron-deficiency anemia
·         Folate-deficiency anemia
·         Vitamin B-12 deficiency

If the provider notes that the antepartum patient does have an anemia, the coder should query the provider to get specificity on the anemia, and have the record amended to reflect the correct diagnosis.  If antepartum anemia is an ongoing part of the antepartum care, this diagnosis should also be reflected consistently in the OB antepartum flow sheet documentation.   Coders cannot make the causal relationship “jump” to anemia, even though a CBC or other lab test may indicate a low Hgb or HCT.  Only a provider can document what type of anemia it is. 

In ICD9 we only have the choice of coding to codes set 648.2X  which states  “maternal anemia complicating pregnancy, childbirth, or the puerperium.  Yet, in ICD-10 we have the option to code with more specificity for distinguishing a complication of the antepartum period/pregnancy, the delivery/childbirth, or the postpartum/puerperium time frame.
·         O99.01X Anemia complicating pregnancy,
·         O99.02 Anemia complicating childbirth
·         O99.03 Anemia complicating the puerperium

ACOG (American College of Obstetrics and Gynecology) has stated that in a non-pregnancy related blood loss, the two main objectives of managing an acute onset of abnormal uterine bleeding are 1) to control the current episode of heavy bleeding and 2) to reduce menstrual blood loss in subsequent menstrual cycles.  So with this information, coders really need to review carefully any references to an “anemia”.   The anemia referenced in a Gyn patient may be the primary diagnosis for a surgical treatment, but the secondary reasons behind the blood loss, may be endometriosis, polyp or even a neoplasm of the uterus, cervix or vaginal area.

Below you will find some quick case examples, and you will note we have not provided any diagnoses with them.  These examples are for you to consider, and ponder the question of whether or not to query for additional information.   These case studies are relevant for those coding both for the facility, and for a physician office type setting. 

Quick Case Example/Coder Q&A:

A 35-year-old mother of three undergoes a transvaginal hysterectomy for prolapsed uterus and menometrorrhagia. Her hemoglobin level is 11.5 g/dL before surgery and 9.0 g/dL after surgery.
1.       Does she have acute blood loss anemia?
2.       Was the procedure complicated by unexpected hemorrhage?
3.       Should the coder query?

Answer: She does have acute blood loss anemia; supported by the fact that she lost an additional 2.5 g/dl of blood post surgery.  However, the patient was anemic pre-operatively too.  In addition, the patient sustained additional blood loss  due to the hysterectomy surgery. The issue with the above case is the physician did not clarify if this was an “expected” amount of blood loss, or if this was an “unusual or hemorrhagic” amount of blood loss that occurred within the surgery, or if the blood loss would be considered a “surgical complication”.   To be able to code the diagnosis  correctly the physician would need to amend the documentation to reflect the blood loss's significance and any causal relationship with the hysterectomy ( anemia, post op or intra op hemorrhage)  and if the blood loss is a “complication” .    Since the coder does not have enough information to adequately code the scenario a query should be done prior to any billing going out.

Quick Case Example/Coder Q&A
A 31-year-old female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG and hCG titer of about 18,000.  Patient complains of excessive bleeding – soaking 2 pads prior to presentation at the Emergency dept.  Patient examined by OB provider to rule out ectopic pregnancy or rupture of corpus luteal cyst.  CBC performed, Hgb = 12 HCT 35%.  Abdominal US was performed, ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with confirmed findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. Hbg post surgery = 7.9  Hgb post transfusion = 9.2
Diagnosis:  Right ruptured ectopic pregnancy with hemoperitoneum and anemia secondary to blood loss.
1.       Does she have acute blood loss anemia?
2.       Was the procedure complicated by unexpected hemorrhage?
3.       Should the coder query?

Answer: She does have acute blood loss anemia; supported by the fact that she lost 4.1 g/dl of blood between arrival and post surgery.  The patient did have additional blood loss due to laparoscopic surgery. The physician did not clarify if this was an “expected” amount of blood loss, but stated she had a hemoperitoneum which can be considered “causal” for hemorrhage prior to surgery.  The documentation did not reflect an “unexpected” hemorrhage, so this blood loss would not be considered a complication of surgery.  In addition, the physician also noted the anemia secondary to blood loss in his final diagnosis.  This case would not necessarily require a query.

Quick Case Example/Coder Q&A
PREOPERATIVE DIAGNOSIS: Postpartum hemorrhage.
POSTOPERATIVE DIAGNOSIS:
 Postpartum hemorrhage.
PROCEDURE:
 Exam under anesthesia. Removal of intrauterine clots.
ANESTHESIA:
 Conscious sedation.
ESTIMATED BLOOD LOSS:
 Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.
COMPLICATIONS:
 None.
INDICATIONS AND CONCERNS:
 This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with the patient. All questions were adequately answered and informed consent was obtained.
PROCEDURE:
 The patient was taken to the operating room where satisfactory conscious sedation was performed. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition.  Will continue close observation for blood loss and transfuse if needed.

1.       Does she have acute blood loss anemia?
2.       Was the procedure complicated by unexpected hemorrhage?
3.       Should the coder query?

Answer: She does have acute blood loss anemia; supported by the fact the physician noted the Hgb of 8.3 and HCT of 24.2.   The patient did have additional blood loss of 200 ml. during the procedure, and was documented that a total blood loss of aprox 2000 ml happened post delivery,  but prior to the return to the OR for clearing of the clots .  It is clearly stated this is a post-partum hemorrhage, and interventions were implemented.   It appears from the documentation the hemorrhage was an “unexpected hemorrhage”  post delivery.  A query should be made to the physician to clarify the hemorrhagic “complication” before appending any diagnosis for hemorrhage complicating surgery.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.   

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