Part 1 GI Bleeding in ICD-10-CM: Ensuring Accurate Coding and Documentation

Introduction:

Accurate coding of gastrointestinal (GI) bleeding in ICD-10-CM is crucial for effective communication, clinical management, and reimbursement purposes. This article presents a comprehensive decision tree for GI bleeding in ICD-10-CM, incorporating important clinical indicators, treatment considerations, and documentation queries.

GI bleeding may present as:

Hematemeis – Vomiting of blood
Melena – Dark, tarry stools
Occult bleeding – Only visible through lab tests
Hematochezia – Bright red blood in stool

Common causes:

Gastric/duodenal ulcers
Diverticulosis
Angiodysplasia
Gastritis, colitis, Crohn’s disease, and more
Tip: Always code specific causes of bleeding when linked with terms like "with" in the Alphabetic Index or Tabular List.

According to the Official Coding Guidelines, a presumed causal relationship exists between certain GI conditions and bleeding when indicated by terms like "with" or "in" in the Alphabetic Index or Tabular List. Unless explicitly stated otherwise by the provider, the combination code for these conditions should be reported. In such cases, the following codes should not be assigned:

K92.0: Hematemesis
K92.1: Melena
K92.2: Gastrointestinal hemorrhage, unspecified

Explanation

When a doctor’s notes or medical record uses phrases like “gastric ulcer with bleeding” or “diverticulosis in hemorrhage,” ICD-10-CM assumes the condition (e.g., ulcer or diverticulosis) is causing the bleeding. You should pick a single code that covers both the condition and the bleeding, rather than using general codes for vomiting blood (hematemesis), black stools (melena), or unspecified GI bleeding.

If the doctor says the bleeding is not caused by the condition, you can use separate codes, but you may need to ask the doctor (query) for clarification.

Endoscopy and Clinical Diagnosis of GI Bleeding

Even if no bleeding is observed during an endoscopy for patients with a recent history of GI bleeding, a code indicating hemorrhage or a code from K92.0 to K92.2 may still be assigned if the physician clinically diagnoses bleeding based on:

Patient history
Other clinical evidence

Coding Rectal Bleeding with Hemorrhoids

When performing a colonoscopy for rectal bleeding, the presence of internal and external hemorrhoids without a specific statement on the cause of the bleeding requires querying the physician. Consider the following:

If hemorrhoids are incidental findings unrelated to the rectal bleeding:
Include codes for hemorrhoids without complications (e.g., K64.9).
Assign K62.5 (Hemorrhage of anus and rectum).

However, if a causal relationship is established between the bleeding and the hemorrhoids, codes K64.8 (Other hemorrhoids) and K64.4 (Residual hemorrhoidal skin tags) should be assigned.

In code assignments for hemorrhoids, bleeding is considered a nonessential modifier and should not be coded separately as it is included in the code assignment for hemorrhoids.

Understanding the underlying cause of gastrointestinal (GI) bleeding is crucial for accurate diagnosis and coding. Several conditions, such as ulcers, gastritis, angiodysplasia, and diverticulosis, are commonly associated with GI hemorrhage. When the Alphabetical Index includes a "with hemorrhage" option for these conditions, a presumed relationship between the bleed and the underlying condition exists.

However, in cases where the assumption appears clinically inappropriate or conflicting documentation is present, a query should be initiated to obtain accurate documentation and coding.

GI bleeding can have various causes, including digestive system malignancy, Crohn's disease, ulcerative colitis, and gastroesophageal tears. It's important to review the medical record for clinical evidence of blood loss anemia, such as decreasing hemoglobin and hematocrit levels, tachycardia, hypotension, dizziness, and cyanosis.

Treatment options for GI bleeding include transfusions of packed red blood cells (PRBCs) and fresh frozen plasma (FFP), infusion of crystalloids and colloids, and volume expanders like Dextran, Plasmanate, or Albumin. Additionally, iron treatments may be administered.

Physician documentation should be reviewed for secondary diagnoses correlating with the drop in hemoglobin and hematocrit levels, transfusion of blood or blood products, or other relevant treatments. If anemia is documented, a query may be necessary to obtain the specific type of anemia, such as acute or chronic blood loss anemia.

In cases of massive GI bleeding, signs and symptoms of hypotension, hemorrhagic or hypovolemic shock, acidosis, and electrolyte abnormalities should be assessed. Documentation of "hemodynamically unstable" by physicians indicates hypotension and/or shock. However, it's important to note that guaiac positive stools, occult blood in stool, or melena alone are insufficient indicators of gastrointestinal bleed. Additional clinical indicators, such as tarry stools, coffee ground emesis, nursing notes describing blood in stools, drop in hemoglobin and hematocrit levels, hypotension, and transfusion of blood products, are necessary to support the diagnosis.

For coding purposes, it's essential to review the documentation for principal and secondary diagnoses related to gastrointestinal hemorrhage, acute ulcer, trauma, alcoholism, and anemia. Certain exclusions, such as esophageal varices with bleeding in the presence of qualifying conditions or specific admission types, should also be considered. Documentation of Do Not Resuscitate (DNR) status (code Z66) on admission is important for risk adjustment.

If the provider attributes the hemorrhage to anticoagulant therapy, additional codes should be reported to capture bleeding due to anticoagulants. These codes include Hemorrhagic disorder due to existing circulating anticoagulants (D68.32) and Adverse effect of anticoagulants (T45.515A). Depending on the circumstances, either the GI hemorrhage or Hemorrhagic disorder due to extrinsic circulating anticoagulant may be sequenced as the principal diagnosis. Querying the provider for clarification on the relationship between bleeding and anticoagulation is necessary when appropriate.

Few Scenarios

Step 1: Anemia Documented

The decision tree begins by determining whether anemia is documented in the patient's medical records. Anemia often accompanies GI bleeding and serves as a vital clinical indicator.

Step 2: Look for Clinical Indicators of Anemia

If anemia is documented, the next step is to evaluate the presence of clinical indicators of anemia, such as low hemoglobin, hematocrit, or red blood cell count, as well as symptoms like fatigue, weakness, and pallor. These indicators further support the association between GI bleeding and anemia.

Step 3: Coagulopathy Documented

Moving forward, it is important to establish whether a bleeding disorder (coagulopathy) is documented in the patient's medical records. Coagulopathy can contribute to or worsen GI bleeding.

Step 4: Anticoagulation Use

In cases where coagulopathy is documented, it is crucial to assess whether the patient is on anticoagulation therapy. It is essential to ensure that the bleeding disorder is clearly attributed to the anticoagulant and not to other potential causes, such as GI bleed due to acute gastritis or epistaxis due to hypertension.

Step 5: Query Opportunity for Clear Documentation

If the documentation is unclear regarding the relationship between the bleeding disorder and anticoagulation therapy, a query opportunity arises. Physicians should be queried to clarify whether the bleeding is indeed due to the anticoagulant.

Step 6: Clinical Documentation Concepts

To accurately code and document bleeding disorders due to anticoagulants, specific coding concepts and guidelines should be considered. The Coding Clinic advises assigning codes for adverse medication effects if the patient took the medication correctly, or poisoning codes if medication misuse is documented. Additionally, the code for hemorrhagic disorder due to extrinsic circulating anticoagulants (D68.32) should be assigned if any bleeding disorder related to anticoagulation is present, along with codes for specific manifestations (e.g., epistaxis, GI hemorrhage, hematuria). The sequencing of codes depends on the circumstances of admission.

Step 7: Query for GI Bleeding and Anticoagulation Relation

To ensure accurate coding and documentation, healthcare professionals should query the physician to obtain clear documentation regarding the causal relationship between GI bleeding and anticoagulation therapy.

Step 8: Endoscopy with or without Bleeding Control

Endoscopy plays a crucial role in diagnosing and managing GI bleeding. Determine whether endoscopy was performed and whether any bleeding control measures were employed during the procedure.

Step 9: IV Octreotide/Protonix

In some cases, the administration of IV octreotide (a vasoconstrictor) or Protonix (a proton pump inhibitor) may be considered to manage and stabilize GI bleeding.

Step 10: DRG Optimization

Once the relevant clinical information has been accurately coded and documented, it is essential to consider DRG optimization strategies to ensure appropriate reimbursement and proper classification within the Diagnosis-Related Group (DRG) system.

Rule: Clinical Documentation Concepts

Scenario: The patient has a documented bleeding disorder attributed to the anticoagulant. In addition to reporting the bleeding disorder, specific manifestations of the bleeding disorder, such as hemoptysis or hematuria, should also be coded. If the patient experienced Coumadin toxicity or a bleeding disorder due to anticoagulants, and the patient took the medication correctly, the adverse medication effect should be reported with the manifestation code sequenced first. However, if the provider documents that the patient took the medication incorrectly, poisoning should be sequenced as the principal diagnosis. If any bleeding disorder due to the anticoagulant is present, along with a manifestation such as epistaxis, GI hemorrhage, or hematuria, the code for hemorrhagic disorder due to extrinsic circulating anticoagulants (D68.32) should also be assigned. The sequencing of codes depends on the circumstances of admission.

Rule: ICD-9-CM assumption for G.I. bleeding

Scenario: In ICD-9-CM, it was assumed that G.I. bleeding resulted from the G.I. lesion identified (such as angiodysplasia, ulcers, gastritis, diverticulitis, etc.), and a combination code should usually be applied. However, if the physician explicitly states that the bleeding is unrelated to the G.I. condition, both codes for the G.I. condition without hemorrhage and category 578 (G.I. hemorrhage) should be assigned. This advice has been superseded by new guidance provided in Coding Clinic, Third Quarter, page 18, which states that the combination codes describing hemorrhage should not be assigned unless the physician identifies a causal relationship.

Rule: Active bleeding without demonstration

Scenario: Active bleeding does not need to be demonstrated during the hospital stay for the physician to clinically diagnose bleeding. Even if bleeding is not seen during procedures like colonoscopy, a code describing hemorrhage can still be assigned based on the physician's clinical diagnosis. This advice is supported by Coding Clinic references from the third quarter of 2017 and 2018.

Rule: Presumed relationship between diverticulitis/diverticulosis and conditions

Scenario: There is a presumed causal relationship between diverticulitis/diverticulosis and conditions such as abscess, perforation, and hemorrhage. ICD-10-CM assumes a causal relationship between two conditions linked by the term "with" in the Alphabetic Index or Tabular List. A combination code should be assigned unless the provider clearly indicates that the conditions are unrelated. In cases where the assumption in the index appears clinically inappropriate or conflicting documentation is present, a query may be necessary to obtain accurate documentation and code assignment.

Scenario: A patient is admitted with hematochezia and undergoes a colonoscopy. The provider's diagnostic impression includes non-thrombosed and non-bleeding internal hemorrhoids, sigmoid diverticulosis, colonic angiodysplasia, and an adenomatous cecum polyp. Based on coding professionals' understanding and the classification's linkage between bleeding and angiodysplasia/diverticulosis, it is appropriate to assign codes for multiple bleeding sites when more than one finding/possible cause is linked. In this case, codes K57.31 (diverticulosis of large intestine without perforation or

ICD-10-CM PCS Inpatient Coding