![]() ![]() However, when the patient, once stable, begins the evaluation and search for the source of the anemia and after careful study that source is identified, gastritis, esophagitis, erosion, ulcer, AVM, fungating mass…the identified source of the bleeding that caused the anemia is the PDX followed by the type of anemia documented. When a patient presents with signs and symptoms of anemia, treatment of the anemia is begun which may be oral therapy or transfusion, the thrust of care may be associated with the anemia. Hematochezia, usually indicating blood from the rectum.Occult, bleeding seen on laboratory examination only(not GI Bleed).Melena, indicating upper or lower GI hemorrhage.Hematemesis, indicting acute upper GI hemorrhage.Gastrointestinal hemorrhage manifests itself in several ways: Only assign a complication code when the provider documents the anemia is a complication. ![]() When post-operative anemia is due to acute blood loss, assign acute post-hemorrhagic anemia." “If a physician documents postoperative anemia in the medical record, but does not label the condition as a complication, and does not specify acute blood loss, assign anemia unspecified. This applies to both infants and adult patients. This condition could also be documented in older patients as well.Īssign the code for anemia secondary to blood loss (chronic). (Melena is not inherent to colon malignancy).Ĭoding Clinic 2013 3 Q page 4 describes a former 35-week premature infant now eight weeks old who is suffering from iatrogenic anemia due to blood loss due to frequent blood draws. Secondary diagnoses include acute posthemorrhagic anemia and blood in the stool (melena). The provider’s final statement indicated, “Adenocarcinoma of the transverse colon, acute microcytic hypochromic anemia secondary to blood loss due to GI bleeding”.Īssign the malignant neoplasm of the colon transverse colon as PDX. A fungating malignant mass in the right colon was identified. The provider described, ‘etiology of gastrointestinal (GI) bleeding resulting in anemia is to be established.” The patient underwent EGD and colonoscopy with colon biopsy. Trauma, etc., the cause/reason for the anemia is the PDX, however, we always have to keep in mind that the PDX is whatever is the circumstance of the admission, and/or the reason for admission after study.Ĭoding Clinic 2013 3Q page 8 describes a patient who presents with generalized weakness, severe hypochromic microcytic anemia, and melena. When the reason for the anemia is identified, sickle cell anemia, gastrointestinal bleed (ulcer, erosion, AVM, etc.). Chronic blood loss anemia is a loss of blood over a period of time due to iron deficiency, condition of the bone marrow, or slow bleed of the gastrointestinal tract. Trauma, gastrointestinal bleed, and intraoperative/postoperative events are the most common reasons for acute blood loss anemia. Acute blood loss anemia is a sudden loss of blood over a brief period of time. Coding Clinic 4Q 2020 p 6,7 is a good reference.īlood loss anemia is either chronic or acute. Experimental gene therapy is being researched in clinical trials to relieve these patients from having to take daily hydroxyurea reducing the frequency of painful crises and the need for frequent blood transfusions. Many sickle cell anemia patients suffer from pain syndrome and anemia symptoms. Since the RBCs/haemoglobin are the oxygen-carrying protein within the RBC, the abnormal shape inhibits the function of the RBC. Sickle cell anemia/haemoglobin SS is an inherited type of anemia in which the red blood cells/haemoglobin are distorted or sickle-shaped making them fragile and prone to rupture. Some patients present for evaluation with one or more of the above symptoms, others may have no symptoms however anemia may be detected by a simple blood test called a complete blood count (CBC). Symptoms of anemia include fatigue, pale skin, heart palpitations, dizziness, and shortness of breath. Let’s explore anemia, medical coding solutions, sequencing, and more.Īnemia in the truest clinical sense is when the blood lacks enough red blood cells (RBCs)/haemoglobin or lacks healthy red blood cells/haemoglobin. Often once anemia has been stabilized, work up to identify the cause is undertaken. Many times, anemia requires a query for the type being evaluated and/or treated. As coders, we all face challenges when it comes to assigning codes that best describe anemia being treated. ![]()
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