What should you call that low H/H?

Anemia seems to have a surprising amount of baggage.

Proceduralists are scared of getting dinged with “post-op anemias” and GI docs and hospitalists claim their CDI departments ask them to “lie in the chart and call everything acute blood loss anemia.”

I hope that’s not the case…and I don’t think it is.

Let’s dig in….

The major problem for anemias is specificity, specificity, specificity.

What do I mean?

You must be specific about:

• Acute versus chronic

• A clinical diagnosis (when possible) versus pathological description

• The source of a bleed

Let’s look at some examples:

Acute bleeding esophageal ulcer > “Esophagitis”

Iron Deficiency Anemia due to heavy menstrual periods > “Microcytic anemia”

Chronic blood loss anemia due to duodenal AVM > “Stool occult positive”

Acute blood loss anemia from diverticular bleed > “Low H/H”

The above examples had a bunch of GI bleeds so let’s talk about them. That’s a top reason for hospital admissions.

There are two top documentation concerns with GI bleeds:

1. Coders can’t assume someone has acute blood loss anemia (ABLA) just because you transfused them blood. You must document “acute blood loss anemia” as a problem. FYI, you can have acute blood loss anemia and not require a transfusion.

2. Coders can’t assume the ABLA is related to the GI bleed. Link it to the GI bleed by saying “due to.” For example: Acute blood loss anemia due to gastric ulcer. Notice also I was specific about the source of bleeding - not just upper or lower.

   • Some are uncomfortable linking the source if active bleeding isn’t seen on EGD / colonoscopy or there were no clear stigmata of bleeding. It’s okay to use uncertain words like “likely," ”presumed,” or “suspected” in the inpatient setting.

This doesn’t need to result in more documentation. My note often looks something like this:

The reason some interpret CDI departments as “encouraging them to document acute blood loss anemia to make more money” is because it is a CC. Chronic blood loss anemia is not. Again, it can’t be assumed just because someone has a GI bleed.

To better understand this and the next section, make sure you’ve read my previous issue on MCC’s, CC’s, RAMI and CMI:

I usually simply encourage specific and accurate documentation and avoid MCC vs CC’s. But, to show the impact of specificity in this case, see the table below:

By the way, listing out individually anemia, thrombocytopenia and leukopenia OR “all cell lines decreased” will not get you the same credit as pancytopenia. You must call it pancytopenia.

The following are not MCC’s or CC’s but still impact quality metrics, your observed to expected death ratio, etc. These diagnoses will have more impact than pathological descriptions such as microcytic or macrocytic anemia: (again, check out my article above to understand those)

• Iron deficiency anemia

• B12 deficiency anemia

• Chronic blood loss anemia

• Anemia due to CKD

So, what about post-op anemias and complications?

Well, anyone in the CDI world knows procedural complications are…complicated…right now. So, I’m going to avoid diving into that hornet’s nest 😰.

But let’s talk about PSI 9.

CMS tracks specific complications with inclusion and exclusion criteria. The two major buckets are PSI’s (Patient Safety Indicators) and HACs (Hospital Acquired Conditions).

PSI 9 is Perioperative hemorrhage or hematoma rate. However, this is only triggered if a PROCEDURE is involved to TREAT the hemorrhage / hematoma such as to control the bleeding or evacuate a hematoma.

Additionally, your patient would be excluded if they have a coagulation disorder (including thrombocytopenia) or are on an anticoagulant or antiplatelet (and there is documentation suggesting the bleeding is due to the anticoagulant - not simply that the patient is on it).

If you want to know more: this is CMS’s PDF file on it.

Two last comments on complications:

1. Documenting acute blood loss anemia after a procedure does not automatically count as a complication.

2. Something being labelled a complication in coding does not equal substandard care.

That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

P.S. We had a baby! Please welcome Oubre Boy #3! Mom and baby are healthy, and our older two have been quite excited about the new addition (surprisingly).

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