Q&A: Coding retroperitoneal hematoma and retroperitoneal hemorrhage

Q: Could you shed some light on the codes of K66.1, retroperitoneal hematoma, an MCC, and R58, retroperitoneal hemorrhage, which is not considered a CC or an MCC? If both are documented within the same medical record, is this considered a conflict between two different diagnoses or is one considered more specific? Both are non-traumatic. Is the hematoma code more appropriate if imaging reveals no etiology of the underlying cause? 

A:  Hemoperitoneum is defined as the presence of blood in the peritoneal cavity that accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Code K66.1, Hemoperitoneum (Hematoperitoneum), qualifies as an MCC as a secondary diagnosis. As the principal diagnosis, it leads to DRG 395-Other Digestive System Diagnoses without CC/MCC with a geometric length of stay (GMLOS) of 2.4 and a relative weight (RW) of 0.6746. Because this DRG is a triplet, the final level could be determined based on the presence of a condition defined by CMS to be either a CC or MCC.  

Now, let’s look at code R58, Hemorrhage, not elsewhere classified (NEC) (which means there is enough documentation but there is not a specific code). Included under this code is also Hemorrhage, not otherwise specified (NOS) (which means there is not enough documentation to select a more specific code), and this condition is not considered by CMS to be either a CC/MCC as a secondary diagnosis. However, if it is the principal diagnosis, it would lead you to DRG 316-Other Circulatory System Diagnoses without CC/MCC, which has a GMLOS of 2 days and a RW of 0.7401. If my math is correct, there is a difference in reimbursement of about $500.

There is no “exclude 1” note under either code, so this tells me both diagnoses can be coded. CDI professionals should be clarifying the etiology of the hemorrhage, and perhaps pair the etiology with the hematoma. The hematoma could possibly be a complication of the hemorrhage.

Now, when you look up retroperitoneal hemorrhage, it is defined as hemorrhage from the kidney into the retroperitoneal space with various causes such as trauma, vasculitis, an aneurysm, a tumor, renal infarct, or a cyst. Retroperitoneal hematoma is defined as one resulting from retroperitoneal hemorrhage. Retroperitoneal hemorrhage and retroperitoneal hematoma are often used synonymously (which I find a bit confusing), defined as an accumulation of blood found in the retroperitoneal space.  

If they were both documented within the same medical record, query the provider as to the principal diagnosis. I question whether either of these diagnoses would necessitate an inpatient admission, but we know that often patients we think should be in observation status are admitted to the hospital instead.

I would also speak with the coding staff. The Official Guidelines for Coding and Reporting, states that codes for signs and symptoms (R00-R99) are acceptable for reporting purposes when a definitive diagnosis has not been established (confirmed) by the provider, or when the sign or symptom is not routinely associated with the definitive diagnosis (in which case the definitive diagnosis code would be sequenced first followed by a code for the symptom).

I would think the bleed would be the reason for admission and the presence of the blood would be a secondary diagnosis, but this would lead us to DRG 314-Other Circulatory Diagnoses with MCC, which has a RW of 1.9582 and a GMLOS of 4.8 (rounded up to five) days, and this just doesn’t make sense to me.

AHA Coding Clinic, Fourth Quarter, 2016 does give us some information regarding postprocedural hemorrhage and hematoma, stating that

“There are clinical differences between postprocedural hemorrhage, hematoma and seroma which require different clinical care. Postprocedural hemorrhage indicates active bleeding usually requiring urgent intervention to prevent hypotension and other life-threatening consequences. Postprocedural hematoma indicates cessation of bleeding with blood clot formation and observation alone may be appropriate. Postoperative seroma is a collection of fluid that builds up under the surface of the skin, most often at the site of the surgical incision or where tissue was removed. The postoperative seroma may develop several weeks after surgery.”

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.