Anemia Query Best Practices: Clarifying Type/Cause

Anemia is a common, treatable condition that is both underdiagnosed and undertreated.

Anemia carries a huge impact on the health and quality of life of patients. The average per-patient costs for anemic patients are 54% higher than for non-anemic patients. The type of anemia or etiology of anemia and any of its complications can increase the resources utilized or costs incurred by the hospital or facility by lengthening the patient’s stay, costs of transfusions and the treatment or medications given.

Ensuring complete and accurate code assignment is one way to recover the costs incurred from treating the patient’s anemia. Failure to clarify the type of anemia may mean the incorrect DRG is assigned and does not reflect the patient’s severity of illness and resources required for treatment of the patient.

Recognizing query opportunities requires understanding the types of anemia, its complications and treatment.

What is Anemia?

In anemia a lower-than-normal number of healthy red blood cells is produced leading to an amount that is insufficient to meet the body’s physiological needs.

What are the Symptoms of Anemia?

Red blood cells carry oxygen throughout the body. When oxygen levels are too low to meet the body’s demands, many different symptoms may develop. These include:

• Fatigue
• Shortness of breath/dyspnea
• Dizziness/hypotension
• Frequent infections
• Heart Palpitations/tachycardia
• Headache
• Pallor
• Pulsatile tinnitus
• Altered mental status/cognitive issues

What are the Types of Anemia?

In general anemia can be divided into two groups, acquired anemias and inherited anemias. Some anemias may be inherited or acquired.

What are Some of the Types/Causes of Acquired Anemia?

• Anemia of chronic disease
• Acute blood loss anemia
• Chronic blood loss anemia
• Iron deficiency anemia
• Microcytic anemia
• Macrocytic and megaloblastic anemia
• Normocytic anemia
• Pernicious anemia
• Chemotherapy
• Hemolytic anemia

What are Some of the Types/Causes of Inherited Anemia?

• Diamond-Blackfan anemia
• Sickle cell anemia
• Thalassemia
• Aplastic anemia

What Tests are Used to Diagnose Anemia?

Diagnostic tests are performed on the blood or blood forming structures to determine a diagnosis of anemia.

• Blood tests- CBC (complete blood count) measures the amount of red blood cells (hematocrit) and level of hemoglobin (main component of red blood cells) in the blood.

• Bone marrow biopsy
• Peripheral blood smear
• Vitamin B-12 and folate
• Hemoglobin electrophoresis
• LDH, haptoglobin, and total and indirect bilirubin
• Iron studies
• Reticulocyte (immature red blood cells) count

How is Anemia Treated?

Anemia is commonly treated with medication, nutritional supplements. Surgical treatments include blood transfusion, transplant of blood forming cells and surgery to control bleeding.

What are the Clinical Criteria for Diagnosing Acute Blood Loss Anemia?

Recognizing clinical indicators of anemia is essential to identifying opportunities to query for this condition. Clinical indicators of anemia include:

• Symptoms of anemia are not previously present
• A drop in Hemoglobin of 1.0-2.0 or Hematocrit of 3-6% - a smaller decrease is also significant in patients with a lower baseline
• Transfusion(s) of blood or blood products
• Intensive serial monitoring of hemoglobin (Hgb)
• Documented loss of a significant amount of blood (at least 300 cc)
• Low hemoglobin concentration and/or low hematocrit.
  • Females: Hemoglobin <11.9 g/dL (119 g/L) or hematocrit <35 percent
  • Males: Hemoglobin <13.6 g/dL (136 g/L) or hematocrit <40 percent 
• Symptoms are secondary to volume loss, such as lightheadedness, syncope, and hypotension. 

Note: Transfusion is NOT a requirement for diagnosis- clinically monitoring of hemoglobin (Hbg) is sufficient

Coding Challenges

The need for accurate documentation and review of clinical information makes coding anemia challenging. Coders must be able to differentiate between acute and chronic anemia, identify the specific cause (e.g., blood loss (including acuity), chronic disease, hemolytic, due to medications or inherited (genetic) etc.), and understand the impact of underlying conditions.

Clear and detailed documentation from providers is essential for accurate code assignment. Coders may need to query providers for clarification on ambiguous or unclear documentation.

These ICD-10-CM Official Guidelines for Coding and Reporting from chapter 2 provide guidance in sequencing codes for anemia associated with malignancies.

How do you Know When to Query for Anemia?

A query for the presence of and type anemia is appropriate when the documentation supports the patient experiencing signs and symptoms of anemia, meets clinical criteria suggesting anemia and the patient is administered treatment. A clinical validation query is appropriate when there is documentation of a specific type of anemia that is not clinically supported.

Take Aways

• The presence of anemia can significantly increase the cost of patient management
• Anemia is caused by a reduction in or malformation of red blood cells
• Anemia is generally of an acquired type or a hereditary type. Some forms of anemia can be either
• Anemia is diagnosed by tests performed on the blood or blood forming structures such as bone marrow
• Anemia is treated with medication, supplements and/or surgical procedures
• Clinical indicators of anemia are primarily related to symptoms related to lack of circulating oxygen, hemoglobin levels and treatment with blood or blood products
• When clinical indicators of anemia are present in the health record without a documented diagnosis of anemia, it is appropriate to query the provider for clarification

References

• Economic Burden of Anemia in an Insured Population
• AJMC The Clinical and Economic Burden of Anemia
• National Heart, Lung and Blood Institute What is Anemia
• MAYO Clinic Anemia
• Cleveland Clinic Anemia
• ICD-10-CM Official Guidelines for Coding and Reporting 2025
• Acute Blood Loss Anemia-ACDIS Forums
• ICD-10-CM New/Revised Codes: Acquired Autoimmune Hemolytic Anemias
• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2020: Page 7
• ICD-10-CM New/Revised Codes: Anemia Due to Pyruvate Kinase Deficiency Anemia Due to Other Disorders of Glycolytic Enzymes
• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2021: Page 6
• Pinson & Tang CDI Pocketbook Guide