Anemia
Definition
Anemia is defined as a hemoglobin or hematocrit value more than 2 standard deviations below the mean for age.
Acute and Chronic Blood Loss Anemia
|
|
Acute Blood Loss Anemia |
Chronic Blood Loss Anemia |
|---|---|---|
|
Hemoglobin and Hematocrit levels |
During & immediately following hemorrhage, H/H may be stable or increased, then declines with ongoing bleeding or control of bleeding. |
Low (2> SDs below normal for age) |
|
Type |
Normocytic |
Microcytic |
| Etiology |
Massive and Rapid Haemorrhage (surgery or any other injury) |
Chronic bleeding, iron deficiency, chronic disease, chemotherapy, etc. |
Acute Blood Loss Anemia
Acute blood loss anemia is usually evident via hemoglobin level within 3 to 4 hours following blood loss. Acute blood loss anemia is defined as a decrease in hemoglobin or hematocrit significant enough to cause the physician to follow closely or treat (as with a transfusion of PRBCs). There is no specific percentage drop in hemoglobin to define acute blood loss. Repeat testing 6 to 12 hours after the event may reveal the true extent of blood loss.
It is important to recall that often acute blood loss anemia is an expected phenomenon, e.g. after a major surgery. Acute blood loss anemia in this situation is not necessarily a complication but should be documented.
Causes of Blood Loss Anemia include:
Anemia due to acute gastrointestinal bleeding
Anemia due to acute blood loss from surgery
Anemia due to chronic gastrointestinal bleeding
Anemia due to acute blood loss from trauma
Chronic Blood Loss Anemia
Chronic Blood Loss Anemia is caused by long-standing, moderate blood loss.
Neonatal Anemia vs. Anemia of Prematurity
Neonatal anemia is a term often used in documentation that may cause confusion for CDI specialists & coders. It may not be clear if one means “anemia of prematurity” or is referring to anemia in a neonate due to another cause. For clarity, we recommend to NOT use “neonatal anemia” but state more specifically the cause of anemia when it exists, for example: anemia of prematurity.
Anemia of Prematurity: hypo-regenerative (low reticulocyte count), normocytic and normochromic anemia. Physiological hemoglobin nadir: term vs. preterm newborns
Tips for Documentation
Clearly document additional disorders & nutritional deficiencies that contribute to the diagnosis of Anemia
Document the type of anemia (e.g. Blood loss, Aplastic)
Specify ‘acute’ or ‘chronic’ or acute in addition to chronic when possible and appropriate
For nutritional anemias, specify the deficient vitamin or mineral
Link anemia to the underlying cause, mere documentation of CKD or neoplasm is not enough
Blood loss during surgery/procedure, even expected, must be linked and documented
Document postoperative anemia in the progress notes and discharge summary.
Codes cannot be assigned to indicator-like lab reports, blood loss during surgery, transfusion or treatment.
When a patient has a low Hgb, state a diagnosis of “anemia” and always include:
Specificity: Acute, Chronic, Acute on Chronic
Type: Blood loss, deficiency (i.e. iron), dilutional, anemia of chronic disease, post-operative, refractory, aplastic, pernicious, unable to determine
Specificity (AKA duration) and type affect your patient’s Severity of Illness (SOI) and Risk of Mortality (ROM).
*If your patient receives a PRBC transfusion, always document that too