Inpatient Facility Coding & Compliance Alert

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Assign a DRG Code for Cervical Fusion with Anemia

Question: A 45-year-old patient is admitted with a diagnosis of cervical stenosis at the C5-C6 level, for spinal fusion. After surgery, the patient’s hemoglobin drops and he receives a transfusion of one unit of packed red blood cells. The physician documents it as post-operative blood loss anemia. Which DRG should he be assigned into?

Texas Subscriber

Answer: The case is of a spinal stenosis at C5-C6 level, M48.02 (Spinal stenosis, cervical region). This patient develops post-operative blood loss anemia, D50.0 (Iron deficiency anemia secondary to blood loss [chronic]). The condition falls under the major diagnostic category MDC 08 (Diseases and disorders of the musculoskeletal system and connective tissue). He would be a suitable case for the MS-DRG 472 (Cervical spinal fusion w CC).