The frightful site of bloody vomitus or stools often prompts a patient to seek medical care. Red or maroon streaked bloody stools, black-tarry stools; hematochezia, hematemesis, rectal bleeding, GI bleeding, etc., are all evidence of gastrointestinal hemorrhage. Gastrointestinal hemorrhage is usually a straightforward diagnosis: the doctor was able to determine the source of the bleed or not. Simple enough, right? Not always.
Examination of the thought process involved in code selection for conditions associated with gastrointestinal bleeding requires knowledge to navigate the twists and turns through coding conventions, guidelines and Coding Clinic advice, as well as the ability to decipher “clinical speak” into “code speak.” On top of everything else, a coder is always focused on the end goal of reporting an accurate account of the patient condition and the care provided. It is like working a bouncing pinball down the table for the highest score.
This article will review coding conventions, guidelines and Coding Clinic advice to encapsulate some of the challenges in diagnostic code selection for conditions associated with gastrointestinal bleeding,
Identify the Underlying Cause of the Bleed
Many gastrointestinal conditions bleed intermittently (e.g., stomach ulcers, diverticulosis and angiodysplasia) A colonoscopy or EGD may reveal gastrointestinal conditions, but find no active bleeding. Coders must not assume the finding of a gastrointestinal condition during evaluation means that is the source of the bleed. It is the physician’s responsibility to identify a causal relationship between gastrointestinal bleeding and the source or cause of the bleed. Coding Clinic, Second Quarter 2007, page 13, states the physician must link the source of bleeding to the condition to support the assignment of a combination code identifying the condition as “with bleed.” If the physician does not establish a link between the gastrointestinal condition and the bleed, assign the applicable 578-category code; also assign the non-bleeding code(s) for the gastrointestinal condition(s).
Example: Patient presents after two days of nausea and vomiting, leading to bout today of vomiting blood, mostly clots. Discharged documentation states: Hematemesis, suspected to be due to intermittent bleeding from chronic gastric ulcer, possible stomach virus.
Inpatient setting code selection:
- 531.40 Chronic stomach ulcer with bleeding
- 008.8 Viral gastroenteritis
Outpatient setting code selection:
- 578.0 Hematemesis
- 531.70 Chronic stomach ulcer without mention of complications
Multiple GI Conditions
Evaluation for GI bleeding may reveal multiple conditions, of which any could be the source of the bleed. If documentation does not clearly identify the cause of the bleed, Coding Clinic, Third Quarter 2005, page 17, advises coders to query the physician on the source of the bleed. If the physician is not able to determine the site or cause of the bleed, assign code 578.9, Hemorrhage of gastrointestinal tract, unspecified, along with codes to identify each of the GI conditions. Select the non-bleeding combination code option, when applicable.
Combination Code or Multiple Codes?
Many gastrointestinal disease codes are combination codes that identify the condition as with or without bleeding, where as other codes do not indicate the presence of hemorrhage in a single code. Based on physician documentation, selecting a between combination codes describing “with” or “without bleeding,” is not difficult.
- Bleeding esophageal varies
- Acute bleeding duodenal ulcer
In an early edition of Coding Clinic, September-October, 1985, page 9, we find direction to assign two codes when a GI condition is identified to be the source of the bleed and a combination code does not exist to describe “with bleeding.” In these cases, assign the code for the condition and a code to identify gastrointestinal bleeding.
- Bleeding esophagitis
530.82 Esophageal Hemorrhage
- Adenocarcinoma of the ascending colon with hematochezia
578.1 Blood in stool
153.6 Malignant neoplasm of ascending colon
Nonessential modifiers throw a couple twists into the code selection process. They are supplementary terms, enclosed in parentheses, found in both the Index and Tabular. The presence or absence of these terms in physician documentation has no impact on the code, but add to the thought process in determining the need for additional codes.
For example, the Index lists hemorrhagic as a nonessential modifier in the main term Enteritis, which is the main index term for Crohn’s disease. Hemorrhagic is also a nonessential modifier for the main term for ulcerative colitis. Bleeding is an inherent characteristic or integral part of the disease process of Crohn’s disease and ulcerative colitis, thus gastrointestinal bleeding is not a separate codeable condition when related to these conditions.
- Colitis (acute) (catarrhal) (croupous) (cystica superficialis) (exudative) (hemorrhagic) (noninfectious) (phlegmonous) (presumed noninfectious)
- Enteritis (acute) (catarrhal) (choleraic) (chronic) (congestive) (diarrheal) (exudative) (follicular) (hemorrhagic) (infantile) (lienteric) (noninfectious) (perforative) (phlegmonous) (presumed noninfectious) (pseudomembranous)
Another twist is that Coding Clinic, Second Quarter 2008, page 15, points out Inclusion Terms listed in the Tabular also act as nonessential modifiers, stating GI bleeding due to acute ischemic colitis would be reported with one code, 557.0, Acute vascular insufficiency of intestine. The term hemorrhagic is an Inclusion Term listed under code 557, indicating hemorrhage, is an integral part of this disease process. An additional code to identify GI bleeding is not assigned.
557.0 Acute vascular insufficiency of intestine
ischemic colitis, enteritis, or enterocolitis
massive necrosis of intestine
Hemorrhagic necrosis of intestine
Intestinal infarction (acute) (agnogenic) (hemorrhagic) (nonocclusive)
Code 569.3 Hemorrhage of rectum and anus reports blood loss from the rectum or anus. Physicians may document “rectal bleeding” when speaking of gastrointestinal bleeding or hematochezia. Physicians recognize rectal bleeding as blood exiting the body through the rectum and anus. They may document blood in the stool and rectal bleeding interchangeably during the admission. However, code selection is based on the source or site of the bleeding; the source of the bleed may or may not be determined to be the rectum or anus.
Code 569.3 Hemorrhage of rectum and anus is a site specific code, like codes 534.40 Bleeding gastrojejunal ulcer and 456.0 Bleeding esophageal varies are specific to those anatomical sites. If the work-up does not determine the source of bleeding to be located in the rectum or anus, it is inappropriate to assign code 569.3 Hemorrhage of rectum and anus. Assign code 578.1 Hematochezia for documentation of blood in the stool. In cases of an underdetermined site or cause of “blood loss exiting the body through the rectum and anus,” code 578.9 Hemorrhage of gastrointestinal tract, unspecified.
In the setting of rectal bleeding with hemorrhoids, without physician documentation of a causal relationship between the hemorrhoids and rectal bleeding, Coding Clinic, Third Quarter 2005, page 17, states to query the physician for clarification as to whether the hemorrhoids are the source of the bleed or an incidental finding.
No discussion on GI bleeding would be complete without the mention of anemia. Anemia is a common condition that is often under-documented in detail and a high likelihood of association to GI hemorrhage.
GI bleeding can be grouped into what is known as “fast bleed” and “slow bleed.” Using this concept, fast bleed can usually point to an acute blood loss anemia, where as a slow bleed usually points to an intermittent or a chronic blood loss anemia. It is possible for a slow bleed to develop into a fast bleed, or both conditions can exist in the same patient at the same time but at different sites. It is possible for a patient to have chronic blood loss anemia and acute blood loss anemia at the same time
Review of the ICD-9-CM Index finds separate subentries for acute blood loss anemia and chronic blood loss anemia, each at the same indention level. General Coding Guideline, Section I.B.10 Acute and Chronic conditions states when separate codes exist for both the acute and chronic phase of a disease, assign codes for both conditions, sequencing the acute condition code first.
If the clinical picture and documentation identify the diagnosis of acute and chronic blood loss anemia, it is appropriate to code both 285.1 Acute blood loss anemia and 280.0 Chronic blood loss anemia.
This is further supported by Excludes Notes under each code (i.e., 280.0 excludes 285.1 and 285.1 excludes 280.0.). The use of excludes notes here should be interpreted to mean “this condition is coded elsewhere” or in other words, also code the excluded condition if clinically supported and documented. If in doubt, query the physician for clarification.
Assign the default code, 280.0 Anemia secondary to blood loss in the absence of documentation on the acuity of blood loss anemia.
Selection of the principal diagnosis is always based on the condition established after study to be chiefly responsible for occasioning the admission of the patient to hospital care, for an inpatient admission.
It may be necessary to consider the focus of care in conjunction with the reason for admission when evaluating what code to select as the principal or primary diagnosis. Determine the condition(s) treated. Did the patient receive meds to help slow or stop the bleed? Was the source of the bleed treated directly? Did the patient receive blood?
Follow Outpatient Coding Guidelines to determine code selection and sequencing for outpatient encounters the primary reason for care.
Navigating through the various coding conventions, guidelines, regulatory requirements and documentation challenges can sometimes turn the simplest clinical encounter into a dashboard of flashing lights with pings, twists and turns when it comes to determining code assignment. These tips on applying coding conventions and guidelines can be used in any applicable coding scenario. Becoming a pinball wizard takes some time at the table, just like developing the thought process that goes into code assignment.
Danita Arrowood is an AHIMA Approved ICD-10-CM/PCS Trainer and an educator/medical coding educator with Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. Arrowood develops content materials for ICD-9-CM and ICD-10-CM/PCS and provides clinical documentation improvement education.
Take the quiz and test your knowledge on page 2.
1. Patient presents after two days of nausea and vomiting, leading to bout of vomiting blood today, mostly clots. Discharge Diagnosis: 1) Hematemesis, unknown origin; 2) Chronic gastric ulcer; 3) Reflux esophagitis. Select the correct code set(s).
A. 578.0, 531.40, 530.11
B. 530.70, 530.11, 530.82
D. 578.0, 531.70, 530.11
2. Patient admitted with hematemesis. EGD finds an acute duodenal peptic ulcer as the source of the bleed. NG tube placed. Patient was treated with IV fluids and IV proton-pump inhibitors.
A. 578.0, 532.00, 45.13, 96.07
B. 532.00, 45.13, 96.07
C. 533.00, 578.0, 45.13, 96.07
D. 533.00, 45.13, 96.07
3. Patient presents with rectal bleeding, abdominal pain and constipation. Colonoscopy reveals a rectal polyp, inflamed and red-oozing serous fluid. The polyp was removed with cautery, no further bleeding was seen.
A. 569.0, 569.3, 48.36
B. 569.3, 211.4, 45.42
C. 211.4, 45.36
D. 211.3, 45.42
1. D: The source of bleed associated with hematemesis is not known. Chronic gastric ulcer and reflux esophagitis were not mentioned to have any complications.
2. B: The source of the hematemesis was determined to be the duodenal ulcer, assign only the combination code 532.00 Acute duodenal ulcer with hemorrhage. Category 533 Peptic ulcer, site unspecified, has an Excludes Note directing code selection to codes 532.0-532.9 for peptic duodenal ulcer.
3. A: The source of the bleed was determined to be a polyp in the rectum. Code 569.0 Rectal polyp does not identify rectal bleeding in the code description, so it is necessary to assign a second code 569.3 for the rectal bleeding. Since the rectal polyp was the source bleed and treatment involved removal of the rectal polyp, code 569.0 rectal polyp is sequenced as the principal diagnosis.