Inpatient Facility Coding & Compliance Alert

Question: An inpatient underwent hip replacement. The diagnosis on the discharge summary was anemia due to surgery. In addition, the provider stated on the discharge summary that, “There was no evidence of further blood loss; therefore it seemed to be due to surgery, which apparently had resulted in a fair amount of bleeding.”

A different provider on a progress note during this patient’s stay stated anemia due to blood loss during surgery.

Just anemia due to surgery would be 285.9. However, anemia due to blood loss could be either 280.0 or 285.1. Does it have to state acute when due to surgical blood loss? Please advise which diagnosis code for the anemia to use.

Answer:  Acute blood loss from any cause—GI bleeding, trauma, surgery—may result in anemia. One might think that anemia ought to be a self-evident, intrinsic consequence of acute blood loss, but from a coding perspective, it is a separate identifiable condition that contributes independently to patient risk and severity of illness.

The actual definition of anemia is “decreased red blood cell volume,” but hemoglobin/hematocrit levels are the usual surrogate measures used clinically. If a patient with acute bleeding loses enough blood to become anemic, the diagnosis of acute blood loss anemia is appropriate. This definition also encompasses patients who have preexisting anemia and become more anemic due to bleeding. Even if the amount of blood lost following surgery is expected and routinely associated with the procedure, acute blood loss anemia is still present if anemia occurs. A common example of this is substantial bleeding and consequent anemia associated with joint replacement surgery. Blood transfusion is not required to substantiate the diagnosis of acute blood loss anemia. However, if a transfusion is necessary, acute blood loss anemia is almost certainly present, since transfusions are not given to patients who don’t have anemia or will not become anemic.

Concerned surgeons can be reassured that the code for acute blood loss anemia is not classified as a “complication of surgery.” This diagnosis will not adversely impact a surgeon’s complication rates or quality scores.

In contrast to acute blood loss anemia, a diagnosis of “postoperative hemorrhage” may result in coding of a surgical complication. Based on coding guidelines, the “complication” code for post-op hemorrhage should not be assigned unless a physician (attending or consultant) specifically indicates that the hemorrhage was due to, or resulted from, the procedure. Unfortunately, many coders mistakenly believe that the term “post-op” establishes this connection.

The term “post-op” should be used judiciously to describe a condition that occurs after surgery (such as arrhythmia, atelectasis bleeding, fever, ileus, renal failure, urinary retention, etc.) to avoid improper coding of a “complication” of the procedure. Complication codes are intended for conditions that are unusual or unexpected—not something commonly associated with the procedure—and then only when specifically connected to the procedure by a physician (that is, when a cause-and-effect relationship is established). Finally, when a postoperative event is associated with a preexisting condition or preoperative diagnosis, it should be clearly documented as such and not as a result of the procedure.

In summary, acute blood loss anemia occurs frequently in patients with acute bleeding from any cause and is a significant indicator of severity of illness that should be clearly documented in the medical record. The term “postoperative hemorrhage” may lead to incorrect coding of a complication of care. Physicians should be cautious when using the term “post-op” to describe any condition since it may be misinterpreted as meaning “due to surgery,” resulting in the assignment of a “complication” code.