Coding, Classification and Reimbursement

Anemia of chronic disease

  • 1.  Anemia of chronic disease

    Posted 08-29-2018 18:50
    Edited by Sharon Morris 08-29-2018 20:27
    physician states patient with anemia of Chronic disease. Patient has CKD. Physician did not connect the two. How would you code the anemia?


    Sharon Morris

  • 2.  RE: Anemia of chronic disease

    Posted 08-30-2018 09:05
    The Index includes the "in" chronic kidney disease as subterm of anemia.  Guidelines now include:

    The word "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for "acute organ dysfunction that is not clearly associated with the sepsis"). For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related."

    Sheila Goethel
    Coding Services Senior Manager

  • 3.  RE: Anemia of chronic disease

    Posted 08-30-2018 09:21
    When coding this code the CKD first and anemia of CKD secondary...the patient has anemia due to the CKD. The encoder follows it through well. As Sheila pointed out with the guidelines follow them and you will be fine.

    Beth Kosman, RHIT, CCS, CCS-P
    HIM Director
    Ringgold County Hospital

  • 4.  RE: Anemia of chronic disease

    Posted 08-31-2018 06:14
    ​The Alphabetic Index has the following entries after Anemia, due to:

    - - chronic disease classified elsewhere NEC D63.8
    - - chronic kidney disease D63.1.

    Does the patient have any other chronic diseases besides CKD?
    I encourage everyone to look at the Index and all the entries at the same level of indentation for Anemia, with/due to, and in.  If a patient has more than one of these conditions and anemia and the provider does not specifically document the cause of the anemia, how many anemia codes is the coder supposed to assign?

    Lawrence Barr

  • 5.  RE: Anemia of chronic disease

    Posted 09-01-2018 15:36

    In my humble opinion, the guidelines tell us what to do.  If the anemia is associated with other chronic diseases, then the anemia with that particular chronic disease needs to be coded.  I have coded for Hospice for many years, and I regularly report anemia in neoplastic disease, and in CKD along with other chronic conditions such as hypothyroidism.  So as long as they are all treated, shouldn't we be reporting them?

    From my research there are different tests, and treatments.  While anemia in CKD may indicate a decrease in EPO, anemia in neoplastic disease would depend on the various mechanisms involved. For accurate reporting, data collection and research, assigning the right anemia code with chronic diseases is imperative.

    Chronic diseases

    Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) (2019 Official Coding Guidelines)


    Theresa Bradshaw
    Coordinator, Medical Coding Certificate Program

  • 6.  RE: Anemia of chronic disease

    Posted 09-02-2018 13:55

    I'm not comfortable with the assumption either. If a patient has CKD, cancer and hookworm disease, are we supposed to use three separate codes for the anemia?  Are we to assume a connection if the patient has only one chronic disease and query for the etiology if they have multiple chronic illnesses?

    Laurie Zawiskie
    Coder III

  • 7.  RE: Anemia of chronic disease

    Posted 09-03-2018 10:45
    ​Looking at your example from the index Lawrence, it does look like you would code it more than once, but I don't agree with that.  Maybe this is a question for Coding Clinic?

    Christina Donahue-Taylor
    Section Head-Coding

  • 8.  RE: Anemia of chronic disease

    Posted 09-03-2018 15:43

    Anemia is just one example.  Look up Failure, heart, congestive:

    - - congestive I50.9
        - - - with rheumatic fever (conditions in I00)
               - - - - active I01.8
               - - - - inactive or quiescent (with chorea) I09.81

    What if a patient has HTN and multiple valve disease with CHF?  Multiple valve disease is assumed to be rheumatic.
    How many CHF codes should be assigned.  Should I09.81 be assigned?  If the underlying cause is not documented the term "with" means the connection is assumed.

    These are just 2 examples.  I am pretty sure if one reviews the entire Index, other examples can be found.  This is a problem with the new "with"/"due to"/"in" Guideline.  Also note how terms after "with", "in" and "due to" are inconsistent.  This is especially true for anemia.  Per the Guideline, all entries should be evaluated after these three terms.  The Guidelines state the three terms are interchangeable.  I try to use a little "common sense" when I code.  Quite often "the connection" is specified - "anemia due to ckd".  However, take it to an extreme.  As another poster suggested, what if a patient with CKD, a GI Bleed, active neoplasm receiving chemotherapy and a deficiency is diagnosed with "anemia".  How many codes are you going to assign?  Are you going to send cases like this back for a query?  How many codes are you going to enter to see if there is any DRG change?

    Lawrence Barr

  • 9.  RE: Anemia of chronic disease

    Posted 10-06-2018 12:47
    Don’t we code diabetes with all other medical conditions from the list,then I would code anemia the same way with the term “with or in”.

    Wendy Johnson
    Medical Coder
    Chicot Memorial Hospital

  • 10.  RE: Anemia of chronic disease

    Posted 10-08-2018 06:41
    Sharon-the correct code selection for a patient with anemia of chronic disease and who has CKD is to assign the code for the CKD followed by D63.8.

    The Physician doesn't have to link the two to code it that way, that's what the "with" convention means. If a patient has CKD and anemia you automatically assumed they are related.

    Brenda Mohs
    Essentia Health-Sandstone

  • 11.  RE: Anemia of chronic disease

    Posted 10-08-2018 10:17

    Is CKD the only chronic disease the patient has?  The provider documented "anemia of chronic disease".  Maybe that is what the provider meant.  How many "anemia of chronic disease" codes are supposed to be assigned when multiple chronic diseases are documented?

    The following is the complete listing of entries after the main entry "Anemia, due to" which the Guidelines and the Index clearly state is equivalent to the terms "with" and "in".

    - due to (in) (with)

    - - antineoplastic chemotherapy D64.81

    - - blood loss (chronic) D50.0

    - - - acute D62

    - - chemotherapy, antineoplastic D64.81

    - - chronic disease classified elsewhere NEC D63.8

    - - chronic kidney disease D63.1

    - - deficiency

    - - - amino-acid D53.0

    - - - copper D53.8

    - - - folate (folic acid) D52.9

    - - - - dietary D52.0

    - - - - drug-induced D52.1

    - - - molybdenum D53.8

    - - - protein D53.0

    - - - zinc D53.8

    - - dietary vitamin B12 deficiency D51.3

    - - disorder of

    - - - glutathione metabolism D55.1

    - - - nucleotide metabolism D55.3

    - - drug -see Anemia, by type -see also Table of Drugs and Chemicals

    - - end stage renal disease D63.1

    - - enzyme disorder D55.9

    - - fetal blood loss P61.3

    - - fish tapeworm (D.latum) infestation B70.0 [D63.8]

    - - hemorrhage (chronic) D50.0

    - - - acute D62

    - - impaired absorption D50.9

    - - loss of blood (chronic) D50.0

    - - - acute D62

    - - myxedema E03.9 [D63.8]

    - - Necator americanus B76.1 [D63.8]

    - - prematurity P61.2

    - - selective vitamin B12 malabsorption with proteinuria D51.1

    - - transcobalamin II deficiency D51.2

    Look at all the terms at the same level of indentation.  In certain situations how many anemia codes are you going to assign?  What if the patient has CKD, cancer, is on chemotherapy, documented blood loss, some sort of dietary deficiency, and multiple chronic conditions and the physician documents only "anemia" or "anemia of chronic disease"?  Are you going to assign one anemia code or six or some other number of codes in between?  What makes CKD any more special than all the other conditions listed in the index?  I have brought up this point before. 

    Lawrence Barr

  • 12.  RE: Anemia of chronic disease

    Posted 10-08-2018 10:30
    I would list all of them unless the doctor document which one like we would do diabetes or HTN. Anemia shouldn't be no different and besides we are following the the guidelines for "with or in". And anemia don't have specific guidelines, so I would follow those, which don't tell us how many diagnoses code with a category.

  • 13.  RE: Anemia of chronic disease

    Posted 12-04-2018 09:28
    ​I understand coding anemia with CKD but what about coding it without it being "treated"? Do you still code it anyways?

    Melissa Wilson
    Him Coder
    Moses Cone Health System

  • 14.  RE: Anemia of chronic disease

    Posted 12-05-2018 07:53
    ​Per the Guidelines in order to code it the Anemia would need to meet one of the 5 criteria - we can code it if isn't being treated...but meets another one of the criteria.

    Kathy Completa
    Coding and Documentation Educator

  • 15.  RE: Anemia of chronic disease

    Posted 12-05-2018 08:13
    Using the logic that Coding Clinic has given us about the GI bleed in a patient that has multiple conditions that have the "with" hemorrhage in the index I would say we would have to code all that is applicable for the patient unless you queried for clarification.
    I don't like it but that is the rules of the classification system.  The GI bleed one causes me grief too.

    Chrystel Barron, RHIA, CCS, CCS-P, CHTS-TR, CICA
    Coding Education Instructor
    Cleveland Clinic Health System

  • 16.  RE: Anemia of chronic disease

    Posted 12-06-2018 21:07
    Hi, you need to query the provider for the cause of the chronic anemia. The documentation must be explicit and concise.

    Olasunkanmi Peleowo

  • 17.  RE: Anemia of chronic disease

    Posted 12-07-2018 06:14
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    The physician does not have to link anemia with the CKD in order for you to code it that way. CKD is listed under anemia DUE TO, (IN) (WITH).  Anything listed that can be assumed. Your code would be D63.1


    Brenda Mohs, RHIT

    Home Health & LTC Medical Coder

    Essentia Health



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  • 18.  RE: Anemia of chronic disease

    Posted 01-21-2019 18:04

    What is confusing is that it states, "in the code title," but per the index, anemia of CKD is under:
        due to (in) (with)
         chronic kidney disease

    Are we to assume that due to = with as well?

    The only condition under anemia that have the 'with' are the anaerobic glycolysis and pentose phosphate pathway.
    Based on this assumption, if someone has anemia and CKD, you always assume the relationship.

    Looking at the index, some sections have with (due to) (in) and due to (with) (in) while other entries have with and due to not with the non-essential modifiers. Aren't the non-essential modifiers not supposed to change your code?

    I think they provider should link the anemia and CKD to code out D63.1.


    Anthony Neal
    Inpatient Lead Coder
    Sisters Of Charity Providence Hospitals