Anemia Conditions Review and Follow the ICD-10-CM Guidelines for Coding
ICD-10 Guidelines are specific for Anemia Conditions. Proper reviewing of the document as well as following the guidelines will ensure accuracy for coding this condition.
Anemia is a condition in which the number of red blood cells or the amount of hemoglobin (the protein that carries oxygen in them) is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts of the body. When the number of red blood cells is reduced or the amount of hemoglobin in them is low, the blood cannot carry an adequate supply of oxygen. An inadequate supply of oxygen in the tissues produces the symptoms of anemia.
CAUSES
The causes of anemia are numerous, but most can be grouped within three major mechanisms that produce anemia:
- Blood loss (excessive bleeding)
- Inadequate production of red blood cells
- Excessive destruction of red blood cells
Anemia may be caused by excessive bleeding. Bleeding may be sudden, as may occur in an injury or during surgery. Often, bleeding is gradual and repetitive, typically due to abnormalities in the digestive or urinary tract or heavy menstrual periods. Chronic bleeding typically leads to low levels of iron, which leads to worsening anemia
Anemia may also result when the body does not produce enough red blood cells. Many nutrients are needed for red blood cell production. The most critical are iron, vitamin B 12 , and folate (folic acid), but the body also needs trace amounts of vitamin C, riboflavin, and copper, as well as a proper balance of hormones, especially erythropoietin (a hormone that stimulates red blood cell production). Without these nutrients and hormones, production of red blood cells is slow and inadequate, or the red blood cells may be deformed and unable to carry oxygen adequately. Chronic disease also may affect red blood cell production. In some circumstances, the bone marrow space may be invaded and replaced (for example, by leukemia, lymphoma, or metastatic cancer), resulting in decreased production of red blood cells.
Anemia may also result when too many red blood cells are destroyed.
a. Treatment directed at the malignancy
Designate the malignancy as the principal diagnosis, if the treatment is directed at the malignancy. If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, the first listed or principal diagnosis should be assigned as Z51.-, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
b. Treatment of secondary site
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed towards the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
c. Coding and sequencing of complications :
Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:
1) Anemia associated with malignancy
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease).
2) Anemia associated with chemotherapy, immunotherapy and radiation therapy
The anemia code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect (T45.1X5, Adverse effect of antineoplastic and immunosuppressive drugs).
When the admission/encounter is for management of an anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the code for anemia is coded first.
The anemia code should be sequenced first, followed by the appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure, when the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy.
3) Management of dehydration due to the malignancy
The dehydration is sequenced first, followed by the code(s) for the malignancy, when the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration).
4) Treatment of a complication resulting from a surgical procedure
The complication should be designated as the principal or first listed diagnosis if the treatment is directed at resolving the complication, when the admission/encounter is for treatment of a complication resulting from a surgical procedure.
These are