Wiki Anemia Dx - Need some Help!

[tgenius1]

Patient presents for anemia. Dietician documents BMI of 35.6. Patient is treated with iron for the anemia. I coded it D64.9 and Z68.35 but I was cited by the auditor. The first time I was cited for coding it with just the D50.9.

However, I did look at D50.9 and Z68.35 any thoughts?

 

[Riehen]

Does the medical record give any insight into the cause of the anemia? There are a few more specific codes for iron deficiency anemia that might be applicable. Also you need a code from the E66 (obesity) section in order to use the Z68.35 on the claim.
Hope this helps.

 

[mitchellde]

You cannot code the obesity unless it is documented by the provider. And unless there is more to the note than what you have here the code D64.9 is correct for a diagnosis of anemia. The coder is not allowed to determine the diagnosis, we can only code what the document states.