ICD-10-CM TRAINING April 2013, Lecture notes of Pathology

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ICD-10-CM TRAINING

April 2013

Endocrine System and Blood

Disorders

Linda Dawson, RHIT, AHIMA Approved ICD-10 Trainer

Judy Parker, RHIT, CCS, AHIMA Approved ICD-10 Trainer

CHAPTER 3

Diseases of Blood/Blood-Forming Organs

Certain Disorders Involving Immune Mechanism (D50-D89)

“Reserved for future guideline expansion”

““Decreased Red Blood Cell Volume”

Abnormally low hemoglobin/hematocrit levelthe

(Hgb/Hct)

• Etiology:

Blood loss

Decreased or faulty red blood cell production

Destruction of red blood cells

• Look for specific documentation: Type of anemia (i.e. acute blood loss anemia)
• Review: Laboratory/Pathology findings Blood values following a surgical procedure Significant drop of Hgb/Hct Physician's orders for testing, monitoring or for procedures
• Query the physician for: Specific diagnosis relating to these findings Underlying cause of the anemia (e.g., due to long-term anticoagulants, gastric ulcer, neoplasm, or internal bleeding)

DOCUMENTATION/CODING OF ANEMIA

Anemia Due to Blood Loss

• Acute blood-loss anemia Sudden, significant loss of blood over a brief period of time Acute blood-loss anemia may occur following surgery, but it is not necessarily a complication of the procedure Arthroplasty patient averages: Hemoglobin drop 3 grams Hematocrit 10% drop  Anemia, unspecified (D64.9), is the default when postoperative anemia is documented without specification of blood loss

www.aaosnotice.org/2012_Proceedings/adult-knee-BloodLoss.html www.acphospitalist.org/archives/2012/02/coding.htm#sb

ALPHABETIC INDEX:

Anemia (essential) (general) (hemoglobin deficiency) (infantile) (primary) (profound)

postoperative (postprocedural) due to (acute) blood loss D

TABULAR LIST:

D62 - Acute Posthemorrhagic Anemia EXCLUDES 1:

• anemia due to chronic blood loss (D50.0)
• blood loss anemia NOS (D50.0)
• congenital anemia from fetal blood loss (P61.3)

Let’s Code!

Chronic Blood Loss Anemia

NUTRITIONAL ANEMIA

(D50-D53)

Iron Deficiency Anemia (D50) Chronic Blood Loss (D50.0) vs Acute Blood Loss (D62)

Vitamin B12 Deficiency Anemia (D51) Excludes1: Vitamin B12 Deficiency (E53.8) “Not Coded Here” B12 Vitamin Deficiency due to Intrinsic Factor Deficiency (D51.0) Pernicious (Congenital) Anemia

Other Nutritional Deficiencies (D53)

Anemia in Chronic Kidney Disease (D63.1)

Look in the Tabular List:

• “Code first underlying chronic kidney disease (CKD) (N18.-)”

1. CKD and Stage (N18.-)
2. Anemia in CKD (D63.1)

ANEMIA OF CHRONIC DISEASE

Anemia in Neoplastic Disease (D63.0)

“ Code first the neoplasm (C00-D49)” responsible

for the anemia

Code D63.0 Anemia in neoplastic disease as

secondary

 ICD-10-CM Coding Guideline I.C.2.c.

ANEMIA OF CHRONIC DISEASE

ANEMIA DUE TO CHEMOTHERAPY

(D64.81)

ICD-10-CM Official Guidelines 2013:

• Anemia associated with an adverse effect of chemotherapy
• The only treatment is for the anemia
• Sequence the anemia code first followed by the appropriate codes for the neoplasm and the adverse effect

APLASTIC ANEMIA

(D60.- and D61.-)

Failure of bone marrow to produce red blood cells Idiopathic Aplastic Anemia (D61.3) Aplastic Anemia due to other external agents (D61.2) Due to:

• Underlying disease (malignant neoplasm or infection)
• Exposure to radiation, chemicals, or drugs
• Often results from treatment for malignancy