Guest Post: When asked about anemia

by Robert S. Gold, MD

I challenge you to find one textbook of medicine, physiology, or pathology that refers to a category of hematologic abnormality as “acute blood loss anemia.”

But coders are very familiar with that term. They may ask a physician whether a patient has acute blood loss anemia. Or they may ask, “What kind of anemia is this?” And physicians essentially have no chance of ever guessing that they are after “acute blood loss anemia” or even “chronic blood loss anemia.”

What coders really want to know is the cause of the patient’s anemia. Was it anemia due to acute blood loss from a ruptured esophageal varix or from a fractured femur? Was it anemia due to chronic blood loss from hematuria from a patient’s multiple bladder polyps or from menometrorrhagia? Was it anemia due to a chronic infection such as chronic osteomyelitis or chronic hepatitis C? Was it anemia due to the patient’s CKD 4?

That’s why the CDI specialists need know how to take that basic coder impulse and help to ask the right question, and obtain the most accurate documentation for the care the physician provided. After all, it’s the end result that counts—and makes everyone happy.

Editor’s note: This article first appeared in the September 2010 edition of Medical Records Briefing. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in CDI. The goals are data accuracy, profile management, and compliance in the inpatient and outpatient arenas.