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How to avoid queries in documenting anemia

28 Oct 2018

Three parts needed in anemia diagnosis

By: Terryn Spragg, RN/CDIS/CCDS

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If you have patients with a GI bleed, an ORIF of their femur or a cesarean section, chances are their blood loss is reflected in their recent H/H, and qualifies as anemia.

The question is: What do you need to document to clearly reflect this condition, according to ICD-10 guidelines? The important thing to remember is that there are three parts to an anemia diagnosis. You must clearly state “Anemia” as well as the acuity and the type/etiology.

ACUITY: Is this anemia acute, chronic or acute on chronic?

TYPE: Is this anemia due to blood loss, deficiency (iron, etc.), aplastic, dilutional, pernicious, chronic disease (CKD, neoplasm, etc.) or refractory?

Perhaps it’s an acute on chronic blood loss anemia, an acute blood loss anemia or acute blood loss anemia on chronic iron deficiency anemia, etc. Other common types of anemia documentation would include acute anemia d/t chemotherapy, chronic anemia d/t CKD 3 or acute blood loss anemia d/t menorrhagia.

Armed with this knowledge, you can document anemia correctly and avoid a query!