Q&A: Querying for and sequencing anemia

Q: I recently reviewed a chart where the patient received packed red blood cells (PRBC), the hemoglobin and hematocrit were 6 and 21 respectively, the estimated blood loss was only 50 ccs after a surgery, and minimal fluids were given. Would it be appropriate to query the provider for anemia even though they didn't mention anemia explicitly? For example, could I use a multiple-choice query that lists acute blood loss anemia (ABLA) and “other anemia, please specify”? 

A: Yes, the purpose of a query is to identify incomplete, vague, or missing diagnoses and to receive clarification in situations, just as you mentioned. Examples of times when a query would be necessary include the following:

• There is clinical evidence that a diagnosis is present, but there’s no documentation of the condition in the medical record.
• “Cause and effect” language is necessary for the appropriate code assignment
• There is conflicting information in the medical record that requires clarification
• A greater level of specificity is evident but not reflected in the documentation

You may find it helpful to review the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief.

Additionally, a coder cannot assign a code for anemia based solely on the evidence you mentioned unless the physician documents anemia explicitly, so a query would be warranted in the situation you outlined.

We want to make sure that the provider is also documenting the etiology of the anemia when possible because this will assist with making sure the most appropriate codes are assigned and that the sequencing of these codes is accurate. If the patient is receiving chemotherapy and the chemotherapy is the underlying etiology of the anemia, for example, then the anemia code would be sequenced first. If the anemia is related to a neoplasm, then the neoplasm would be sequenced first, followed by a code for the anemia. If a patient is admitted with anemia and the anemia is found to be related to a GI bleed, the GI bleed would be sequenced first as the principal diagnosis and a secondary code for anemia would be used. But if the patient has already been diagnosed with a GI bleed and the admission is focused on treating the anemia, then the anemia would be the principal diagnosis.

So, as you can see, first we have to make sure all the appropriate diagnoses are documented, then we have to consider the circumstances of the admission to make sure they are all sequenced appropriately.

Editor’s note: Sharme Brodie, RN, CCDS, CDI education specialist for ACDIS/HCPro, based in Middleton, Massachusetts, answered this question. Contact her at sbrodie@acdis.org.