Inpatient Facility Coding & Compliance Alert

You need to get “autologous” and “non-autologous” straight in your mind.

You’re less than a year away from ICD-10’s implementation date, which means that you need to highlight areas where you need more detail — and one of those areas is blood transfusions. Right now, you need only know the type of transfusion, but all that changes in ICD-10-PCS.

Check out this example and see how the current documentation won’t fly in 2014.

Confront This Transfusion Example

Suppose you have a transfusion record that indicates the “transfusion of red blood cells, leukocyte reduced.” The medical record also indicates the patient has received treatment for myelodysplastic syndrome pancytopenia secondary to anemia. The discharge summary and progress notes document the transfusion of blood. You Can Report This in ICD-9 Currently, the ICD-9 code system provides codes for transfusion of blood and blood components (Vol. 3, 99.0x series) with respect to type of transfusion (e.g., Transfusion of packed cells, platelets, coagulation factors, other serum, etc.). This is the clinical indicator you need to know to choose the accurate code.

Thus, the existing clinical documentation describes the transfusion of red blood cells, which you should report with:

• 99.04 - Transfusion of packed cells

Break Down What You Need in ICD-10-PCS

Your physician has to capture the transfusion of packed cells (pRBC) with increased specificity if you’re going to properly assign the ICD-10 PCS code.

In other words, the transfusion/administration PCS codes require specific details per ICD-10 PCS guidelines. Transfusion related codes require specific details as follows:

Section (relates to type of procedure): Administration

Body System (refers to general body system): Circulatory

Root Operation (specifies objective of procedure): Transfusion or putting in blood or blood products

Body Part/Region (refers to specific part of body system on which procedure is being performed):

• Peripheral Vein
• Central Vein
• Peripheral Artery
• Central Artery

Approach (is the technique used to reach the site of the procedure):

• Open
• Percutaneous

Substance:

• Red Blood Cells
• Frozen Red Blood Cells

Qualifier (provides additional information about procedure):

• Autologous
• Non-Autologous

Remember, "autologous" means that the cell source comes from the patient. For instance, a patient scheduled for a non-emergency surgery may donate blood for herself that will be stored for the surgery. In that way, she is both the donor and the recipient. Another example is that the patient may have an autologous skin graft, which means the skin is taken from the patient's body and used as the graft. You would use the ICD-10-PCS value of "7."

On the other hand, "nonautologous" means the cell source is not from the patient. The donor and the recipient are not the same person. For instance, if the patient has an emergency surgery and requires a blood from a blood bank, then this blood is "nonautologous." You would use the ICD-10-PCS value of "K."

Here Are Your Possible ICD-10-PCS Options

The following are available codes in ICD-10 for Transfusion of Blood:

Therefore, You Need to Change Your Documentation

The existing clinical documentation provides information on the following Clinical Indicators:

• Section (relates to type of procedure): Administration
• Body System (refers to general body system): Circulatory
• Root Operation (specifies objective of procedure): Transfusion or putting in blood or blood products

However, the existing clinical document lacks the necessary information to provide detailed and specific information on the following indicators:

• Body Part/Region
• Approach
• Substance
• Qualifier

This means that the transfusion records need to be modified. Physicians need to start documenting the required specific details so that you can choose the appropriate ICD-10-PCS code.