December 1, 2016
Our hospital tells us they are developing guidelines for the application of diagnosis codes for acute blood loss anemia post-operatively. They propose the use of lab values pre- and post-op to allow the hospital coders to assign these codes. Is this correct coding?
No, this is not an acceptable practice. The official Coding Guidelines state that “abnormal findings (lab, x-ray, pathologic, and other diagnostic results) are not coded unless the physician indicates the clinical significance. This means the provider would need to document that the blood loss was clinically significant, required intervention, abnormal, or a complication of the procedure to assign a diagnosis indicating any of the preceding circumstances.
*This response is based on the best information available as of 12/01/16.