Coding, Classification & Reimbursement

Clinical validation vs reportable criteria

  • 1.  Clinical validation vs reportable criteria

    Posted 10-09-2018 12:45
    Edited by Lori Drodge 10-09-2018 14:05
    When "acute blood loss anemia, expected" is documented, should the decision for coders to code this documentation be based on:

    •  the fact that the provider documented it only


    • documentation of the condition as well as reportable criteria are met (evaluated, treated, monitored or extended stay)

    Lori Drodge, RHIT, CCS, APPROVED I10 CM/PCS

  • 2.  RE: Clinical validation vs reportable criteria

    Posted 10-10-2018 05:17
    If the clinician notes "acute blood less anemia" (whether expected or otherwise), it must have been determined by lab results, correct? Thus to me it has met the criteria of evaluated. If blood draws are done on a subsequent day or days to see if the Hct has stabilized or is recovering, it is being monitored.

    Post-op patients, especially orthopedic patients, often get initial physical therapy while still in-house. Those with ABLA might not be able to tolerate optimum levels of therapy if their anemia is symptomatic (dizzy, out of breath, sweaty, etc.)

    I found that in the past, surgeons avoided documenting ABLA because they feared it would be viewed as a complication. That's when I started seeing the "expected" bit show up.

    Just one angle on the matter.

  • 3.  RE: Clinical validation vs reportable criteria

    Posted 10-10-2018 13:33
    ​​Thank you for your reply Donna.  This was a short stay in which no labs were done.  Wondering what the thought is about coding conditions that are documented without evaluation, monitoring, treatment or length of stay impact.

    Lori Drodge, RHIT, CCS, APPROVED I10 CM/PCS

  • 4.  RE: Clinical validation vs reportable criteria

    Posted 10-10-2018 14:19

    One thing to consider with "acute blood loss anemia" might as well be stated as acute blood loss with anemia.  I have seen surgeons document this as expected according to the type of surgery and I have also seen surgeons document it based on the amount of blood loss recorded during surgery.  Without treatment of the condition, especially in the era of clinical validation, I don't think this winds up being a condition that you can accurately assign a code to.  Especially with Orthopedic surgeries, the reality is that those surgeries are bloody, thereby technically meeting the ABLA term but if it does not lengthen the stay and there is no aggressive treatment, I just don't think you can ethically code it.

    Karen M. Karban, RHIT, CDIP, CCS
    Sr. Product Manager

  • 5.  RE: Clinical validation vs reportable criteria

    Posted 10-11-2018 08:32
    I tend to agree with Karen.  If the acute blood loss anemia isn't treated then it shouldn't be coded.  This is a brief excerpt from an article written by Dr. Robert Gold  and Dr. William Haik on ABLA due to fractures and GI bleeds.

    "It is not uncommon for patients to lose several hundred cc's of blood into a hip or long bone fracture site (unrelated to the surgery), Haik says. "The drop of the hgb/hct won't occur until after the surgery some 12 to 24 hours later as the plasma volume is restored with hydration, etc.," he says. "And therefore, if addressed or treated, then the physician should get credit for the increased hospital use."
    With a femur (hip/long bone) fracture, says Gold, a patient may lose up to two units of blood whether the patient goes to the operating room or not. And, as Haik suggests, once the patient receives IV fluids, the hemoglobin level falls whether the patient goes to the operating room or not.
    There are two considerations once that drop in hemoglobin happens, Gold says.
    1. If the drop in hemoglobin never reaches a level that meets the criteria for anemia, do not ask the physician to document anemia due to acute blood loss from the fractured femur, because it's not anemia. 
    2. If the hemoglobin does drop low enough to be called anemia but the physician does not treat the patient for it, do not ask anyone to assign a code for it. In general, do not assign a code for a condition that is not treated or followed as it doesn't meet the UHDDS criteria as a valid secondary diagnosis.
    "Sure, ask the physician to document for consistency, but as 'anemia due to acute blood loss from the femur fracture.' Then, if it is treated, code it -if it's not, don't," Gold says.
    Similarly, with a GI bleed or extreme menorrhagia or severe hematuria, a person can easily develop anemia due to acute blood loss, Gold says. Here, unless the patient goes to the operating room, there's no concern about "complications of surgery." However, if the patient does go to the operating room (suture ligation of bleeding duodenal ulcer) or has a procedure (embolization of bleeding submucosal leiomyoma), as long as the documentation is provided as "anemia due to acute GI bleed" or "anemia due to acute blood loss from submucosal fibroid," the 285.1 code should be assigned but not the 998.11 code. 
    "That's because the anemia was not due to any excessive blood loss from the procedure, but from the pathologic condition-and that's not counted as a complication of a procedure anymore," Gold says."

    Arlene Baril, MHA, RHIA, CHC
    Senior Director, Provider Coding & Audit Services
    Change Healthcare, TES Division

  • 6.  RE: Clinical validation vs reportable criteria

    Posted 10-11-2018 09:14

    It appears you are asking about an anemia due to an expected operative blood loss.  First of all, as another contributor has pointed out, it is the blood loss that is either "acute" or "chronic" and the etiology of the anemia.  The term "acute" from a coding perspective does not modify the term "anemia".

    Based on the scenario you have presented, an "expected" anemia due to an "expected" loss of blood resulting from surgery would not ordinarily be coded.  The word "expected" is important in these cases.  Even though coders are supposedly "not qualified" to make clinical determinations and are supposed to assign codes based on the provider's diagnostic statements, it seems we are still held responsible for making such decisions regardless of what the Guidelines state.  I would also take into consideration this case is a "short stay".

    This topic was addressed in Coding Clinic, 3rd 2004, page 4.


    Our surgeons think that anemia due to an "expected" blood loss is integral to procedures. When we query the physician regarding patients whose lab values have dropped significantly after surgery to levels suggestive of anemia, the physicians are refusing to document anemia due to blood loss even if they monitor and transfuse the patient.  They say the patients lost an expected amount of blood.  I have read Coding Clinic, Second Quarter 1992, pages 15-16, and its discussion of postoperative anemia guidelines.  But this issue doesn't give us definitive information to give the physicians that clearly states, "blood loss anemia due to an expected blood loss can be documented and reported when the patient meets the clinical criteria of anemia and the diagnosis meets UHDDS guidelines for reporting other diagnoses."


    Coders should not use blood transfusions or abnormal lab findings as definitive variables in determining whether or not to code blood loss anemia without physician documentation.  If in the physician's clinical judgment, surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the blood loss. This advice is consistent with information previously published in Coding Clinic, Second Quarter 1992, pages 15-16, and Third Quarter 2000, page 6."

    There is a subsequent Coding Clinic, 1st QTR 2007 page 19 which addresses "Postoperative Anemia".  However, this CC does not address if the anemia is "expected".

    I wish I could give you a more definitive answer but in my opinion I believe there are certain coding topics the cooperative parties would prefer not to answer directly.

    Lawrence Barr

  • 7.  RE: Clinical validation vs reportable criteria

    Posted 10-11-2018 16:31

    Thank you for all of your thoughtful replies!  My opinion is that CC4Q16p147-149 has created some confusion.  It states in part, "regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same-as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded".  Treatment is given in sepsis cases and therefore meets reportable criteria.  Code assignment of any condition should be based on 2 things:  1)  how & where it's documented and 2) reportable criteria.  The 2019 Guidelines include:  "As with all other diagnoses, the codes for psychoactive substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses)" I welcome others' thoughts.

    Lori Drodge, RHIT, CCS, APPROVED I10 CM/PCS

  • 8.  RE: Clinical validation vs reportable criteria

    Posted 10-12-2018 08:12
    ​Hello Again!

    I am in total agreement with you.  There is a major problem with Coding Clinic editing.  Coders are being told to code based on provider documentation but then being told to apply the UHDDS guidelines.  Coders are being told we do not possess the expertise to make "clinical" determinations but then we are told we should be making clinical determinations.  We are told coding changes resulting from clinical review are not supposed to be considered coding errors but then they are counted against us in coding accuracy reports.

    Sometimes I feel like suggesting we all employ the "provider documenting a condition is enough to code it" policy as advised in the cited Coding ClinicHowever, we all know what would happen.  The coders would be held responsible for the "errors".  Not Coding Clinic, not the auditors, not CDI reviewers, nor anyone else.  "Poor documentation?"  Too bad, we are not going to fix the documentation.  You deal with it.  "Copy, cut, and paste problem?"  Too bad, we are not going to take the time to educate the providers and  correct the problem, you deal with it.

    Lawrence Barr

  • 9.  RE: Clinical validation vs reportable criteria

    Posted 10-12-2018 08:20
    ​Although this particular scenario is rare (usually the H/H levels are monitored), it highlights the complexity of coding & importance of clinical documentation improvement.

    Lori Drodge, RHIT, CCS, APPROVED I10 CM/PCS