Amputations, Debridement and Spinal Fusion Clinical Documentation

Amputations

 

• Lower Body (include laterality)
    --Hindquarter
    --Femoral Region
    --Knee Region
    --Upper/Lower Leg
       °°High (proximal)
       °°Mid (mid portion)
       °°Low (distal)
    --Foot
       °°Complete or partial ray(s)/metatarsal(s)
    --Toe
       °°High (proximal phalanx)
       °°Mid (PIP joint or middle phalanx)
       °°Low (DIP joint or distal phalanx)
• Upper Body (include laterality)
    --Forequarter
    --Shoulder Region
    --Elbow Region
    --Upper/Lower Arm
       °°High (proximal)
       °°Mid (mid portion)
       °°Low (distal)
• Hand
    --Complete or partial ray(s)/metacarpal(s)
• Thumb/Finger
    --High (proximal phalanx)
    --Mid (PIP joint or middle phalanx)
    --Low (DIP joint or distal phalanx)

Debridement

• Depth:
    --Skin
    --Subcutaneous tissue/fascia
    --Muscle
    --Joint
    --Bone
• Type:
    --Excisional/Sharp
    --Non-excisional
• Specify the type of instrument used

Spinal Fusion

• Column fused
    --Anterior (rounded, smooth portion of spine)
    --Posterior (pedicle, lamina, facet, transverse process of spine)
• Approach
    --Anterior
    --Lateral
    --Posterolateral
    --Posterior
    --Lateral transverse
• Type of device(s) used
    --Interbody fusion device
    --Autologous bone graft
    --Nonautologous bone graft
    --Etc.
• Number of joints fused
    --L1–L3
    --L5–S1
    --Etc.

Lymph Node Chains, Omentectomy and CABG Clinical Documentation

Lymph Node Chains

                                  Lymph Node Chains

 

• Document extent of excision/resection:
    --Entire lymph node chain
    --Portion of lymph node chain
• Document site:
    --Head
    --Right/Left neck
    --Right/Left upper extremity
    --Right/Left axillary
    --Thorax
    --Right/Left internal mammary
    --Mesenteric
    --Pelvis
    --Aortic
    --Right/Left lower extremity
    --Right/Left inguinal

Omentectomy

• Document the body part being resected/excised:
    --Greater omentum
    --Lesser omentum

Lysis of Adhesions

• Document the body part being released/freed, examples:
    --Jejunum
    --Ascending Colon
    --Gallbladder
    --Peritoneum
    --Document the severity of adhesions, such as, complicated,
extensive, etc.

Cleft Palate Repair

• Specify the following:
    --Palate description Hard/Soft/Both
    --Bilateral/Unilateral
    --Complete/Incomplete
    --With/without Cleft Lip Involvement
    --If Cleft Lip involvement—Bilateral/Unilateral

CABG

• Origination/Destination of graft(s)
    --Examples: aorta to RCA, LIMA to LAD (indicate if the LIMA was
used as a pedicle graft)
• Type of graft(s) used
    --Examples: autologous artery, autologous vein, etc.
• Number of sites bypassed
    --Examples: one, two, three, or four, or more
• Excision of autologous graft
    --Identify the vessel
       °°Examples: greater/lesser saphenous vein (left/right), radial artery
(left/right)

Mechanical Device Complications and Socioeconomic Circumstances

Mechanical Device Complications

Mechanical Device Complications

• Body system
• Type of device
• Specific complication
    --Breakdown
    --Displacement
    --Leakage
    --Infection
    --Hemorrhage
    --Pain
    --Embolism
    --Fibrosis
    --Other
• Episode of care
    --Initial encounter
    --Subsequent encounter
    --Sequela
• Document any associated
diagnoses/conditions

Socioeconomic and Psychosocial Circumstances

• Document problems related to:
    --Education/literacy
    --Employment/unemployment
    --Occupational exposure (specify)
    --Housing & Economic
    --Social environment
    --Upbringing
    --Primary support group/Family circumstances
    --Other psychosocial circumstances

Body Mass Index

• Adult BMI (21 years +):
    --19 or less
    --20.0–20.9
    --21.0-21.9
    --60.0–69.9
    --70+
• Document any associated diagnoses/conditions, such as morbid obesity,
malnutrition, etc.
• Pediatric BMI (ages 2–20):
    --Less than fifth percentile for age
    --Fifth percentile to less than 85th percentile for age
    --85th percentile to less than 95th percentile for age
    --Greater than or equal to 95th percentile for age

Reproductive Services

• Document reason for visit:
    --Contraceptive management (specify type)
    --Procreative management (specify type)
    --Pregnancy test or childbirth instruction
    --Pregnancy state, incidental
    --Elective termination of pregnancy
    --Supervision of normal pregnancy (specify trimester)
    --Antenatal screening of mother

Contact with and Exposure To

• Specify what the patient came into contact with, such as:
    --AIDS virus
    --Anthrax
    --Varicella
    --Mold
    --Second-hand tobacco smoke
    --Other (specify)

Retained Foreign Body, Encounter For and External Cause

Retained Foreign Body

Retained Foreign Body

 

• Specify type of foreign body retained, examples:
    --Glass
    --Metal
    --Radioactive
    --Tooth
    --Other (specify)

External Cause

• Document “how” an injury occurred, such as fall, motor vehicle
accident, etc.
• Document “where” an injury occurred, such as home, work, school, etc.
• Document “activity”, such as skiing, ironing, gardening, etc.
• Document “status”:
    --Civilian
    --Military
    --Volunteer
    --Other (specify)
• Important Notes:
    --No national requirement for external cause reporting
    --Some states and payers require external cause codes

Encounter For

• Document the reason for encounter, such as:
    --Examination
    --Pregnancy
    --Adjustment/removal of device
    --Suspected condition, ruled out
    --Other (specify)

History (Personal and Family)

• Document any relevant personal/family history, such as:
    --Malignant neoplasm (specify type)
    --Congenital malformations/deformations (specify type)
    --Allergies (specify type)
    --Chemotherapy
    --Radiation therapy
    --Surgical history
    --Other (specify)

Genetic Carrier/Susceptibility

• Specify genetic carrier of:
    --Cystic fibrosis
    --Hemophilia A
    --Other (specify)
• Susceptibility to disease:
    --Malignant neoplasm (specify type)
    --Multiple endocrine neoplasia
    --Other (specify)

Fractures, Burns and Underdosing Clinical Documentation

Fractures

Fractures

 

• Cause:
    --Traumatic
    --Stress
    --Pathologic
• Location:
    --Which bone?
    --Which part of the bone?
    --Laterality (right, left, or bilateral)
• Type:
    --Non-displaced
    --Displaced
    --Open (Gustilo classification where applicable)
    --Closed (Greenstick, spiral, etc.)
    --Salter-Harris (specify type)
• Encounter:
    --Initial
    --Subsequent
       °°For routine healing
       °°For delayed healing
       °°For non-union
       °°For malunion
    --Sequela (such as bone shortening)
• Include the external cause of the fracture, such as fall while skiing, motor
vehicle accident, tackle in sports, etc.
• Document any associated diagnoses/conditions

Burns

• Type:
    --Corrosion
    --Thermal
• Site:
    --Specify body part
    --Include laterality
• Degree:
    --First
    --Second
    --Third
• Document total body surface area (TBSA) burned (percentage)
• Specify the percentage of third degree burns
• Include the external cause of the burn, such as house fire, stove, acid, etc.
• Document any associated diagnoses/conditions

Underdosing

• Using a prescribed medication less frequently than prescribed, in small
doses, or not using the medication as instructed should be documented
as “underdosing” by the provider
• If the reduction in the prescribed dose of the medication results in a
relapse or an exacerbation of the medical condition for which the drug is
prescribed, the medical condition must also be documented

Coma, Cleft Palate and Gustilo Classification Documentation

Coma

 

• Document:
    --Somnolence, drowsiness
    --Stupor, catatonic stupor, or semicoma
    --Coma, unconsciousness
    --Include any associated skull fracture or intracranial injury if present
• Document the Glasgow (coma scale) score
    --(Typically reported as a total score 0–15)
    --Higher the score = higher functioning
• Also document each assessment area:
    --Eye opening
    --Verbal response
    --Motor response

Cleft Palate

• Specify palate involvement:
    --Hard
    --Soft
    --Hard with Soft
    --Medial
    --Uvula
• Document cleft lip involvement:
    --Unilateral cleft lip
    --Bilateral cleft lip
    --Median cleft lip
• Document any associated diagnoses/conditions

Gustilo Classification

• Specificity for open fractures of the forearm, femur, and lower leg
will require provider documentation to specify Gustilo Type l through
Type lllC:
    --TYPE l: The wound is smaller than 1 cm, clean, and generally caused by
a fracture fragment that pierces the skin.
    --TYPE II: The wound is longer than 1 cm, not contaminated, and without
major soft tissue damage or defect. This is also a low energy injury.
    --TYPE III: The wound is longer than 1 cm., with significant soft tissue
disruption. The mechanism often involves high-energy trauma, resulting
in a severely unstable fracture with varying degrees of fragmentation.
    --IIIA: The wound has sufficient soft tissue to cover the bone without the
need for local or distant flap coverage.
    --IIIB: Disruption of the soft tissue is extensive, such that local or distant
flap coverage is necessary to cover the bone. The wound may be
contaminated, and serial irrigation and debridement procedures are
necessary to ensure a clean surgical wound.
    --IIIC: Any open fracture associated with an arterial injury that requires
repair is considered IIIC. Involvement of a vascular surgeon is generally
required.
• NOTE: Even though the fracture may be described using the terminology
found in the Gustilo classification the provider must document the type
of Gustilo fracture present; coder CANNOT code based on the fracture
description.

OB/Pregnancy, Newborn and Congenital Foot Deformities

OB/Pregnancy

 

Pregnancy

• Specify trimester
    --First (less than 14 weeks, 0 days)
    --Second (14 weeks, 0 days to less than 28 weeks, 0 days)
    --Third (28 weeks until delivery)
• Specify preterm labor/delivery
• Gestational Diabetes needs documentation specification of diet
controlled or insulin controlled
• Document any associated diagnoses/conditions

Newborn

• Birth:
    --In hospital
       °°Specify delivery type
    --Outside hospital
• Document any maternal conditions affecting the newborn
• Specify gestational age and weight of newborn
• Specify congenital vs. acquired conditions
• Document any associated diagnoses/ conditions

Congenital Foot Deformities

• Specify “Congenital” or “Acquired”
• Specify type:
    --Talipes equinovarus
    --Talipes calcaneovarus
    --Metatarsus varus
    --Talipes calcaneovalgus
    --Pes planus (left vs. right)
    --Pes cavus
    --Vertical talus deformity (left vs. right)
    --Other (specify)
• Document any associated diagnoses/conditions

Chronic Kidney Disease, Scoliosis and Acute Renal Failure

Chronic Kidney Disease

Chronic Kidney Disease

 

• Document the stage of CKD
    --Chronic kidney disease, stage 1
    --Chronic kidney disease, stage 2 (mild)
    --Chronic kidney disease, stage 3 (moderate)
    --Chronic kidney disease, stage 4 (severe)
    --Chronic kidney disease, stage 5
    --End-stage renal disease (ESRD)
• Document any underlying cause of CKD such as Diabetes or
Hypertension
• Document if the patient is dependent on Dialysis
• Chronic renal failure without a documented stage will be assigned to
Chronic kidney disease, unspecified
• Document any associated diagnoses/conditions

Scoliosis

• Specify type:
    --Infantile idiopathic
       °°Progressive
       °°Resolving
• Juvenile idiopathic
• Adolescent
• Other idiopathic
• Thoracogenic
• Neuromuscular
• Other secondary
• Other (specify)
• Specify site:
    --Cervical
    --Cervicothoracic
    --Thoracic
    --Thoracolumbar
    --Lumbar
    --Lumbosacral
    --Sacral
    --Sacrococcygeal
• Document any associated diagnoses/conditions

Acute Renal Failure

• Document underlying condition(s) contributing/causing acute renal
failure if known or suspected
• Document if acute kidney injury (AKI) is due to traumatic injury or if due
to a non-traumatic event
• Document if acute renal failure is due to:
    --Acute tubular necrosis (ATN)
    --Acute cortical necrosis
    --Acute medullary necrosis
    --Other (specify)
• Be specific with documentation
    --Acute renal insufficiency and acute kidney disease are not reported as
acute renal failure
• Document any associated diagnoses/conditions

Pathologic Fractures, Cellulitis and Gout Clinical Documentation

Pathologic Fractures

                               Pathologic Fractures

 

• Document location:
    --Bone (distal, proximal, shaft, etc.)
    --Laterality
• Document etiology:
    --Osteoporosis
       °°Disuse
       °°Drug-induced
       °°Postmenopausal
       °°Idiopathic
       °°Postsurgical malabsorption
       °°Other (specify)
    --Neoplastic disease
    --Other (specify)
• Document encounter type:
    --Initial encounter
    --Subsequent encounter
       °°Routine healing
       °°Delayed healing
       °°Nonunion
       °°Malunion
    --Sequela
• Document any associated diagnoses/conditionsx

Cellulitis

• Specify anatomic site
• Laterality:
    --Right
    --Left
    --Bilateral
• Cellulitis of “other parts of limb,” specify:
    --Right
    --Left
    --Upper
    --Lower
• Cellulitis of the “cheek,” specify:
    --Internal
    --External
• Document any associated diagnoses/conditions

Gout

• Specify the type/cause of gout:
    --Drug-induced
    --Idiopathic
    --Lead-induced
    --Primary
    --Secondary
    --Syphilitic
    --With renal impairment (specify the specific renal disease/disorder,
including acuity and/or state)
• Specify the specific joint involved along with laterality
• Specificity acuity of gout:
    --Acute
    --Chronic—With or Without Tophus
    --Gout attack
    --Gout flare
• Document any associated diagnoses/conditions

Hepatic Encephalopathy, Pressure and Non-Pressure Ulcers

Hepatic Encephalopathy

                            Hepatic Encephalopathy

 

• Etiology
    --Due to alcohol
    --Due to drugs
    --Post-procedural
• Acuity
    --Acute
    --Subacute
    --Chronic
• Severity
    --With coma
    --Without coma
• Document any associated diagnoses/conditions

Pressure Ulcers

• Site (include laterality):
    --Elbow
    --Back (upper/lower)
    --Sacral
    --Hip
    --Buttock
    --Ankle
    --Heel
    --Head
    --Other (specify)
• Pressure Ulcer Stage:
    --Stage 1
    --Stage 2
    --Stage 3
    --Stage 4
    --Unspecified
• With gangrene
• Document any associated diagnoses/conditions
• Document if ulcer (including stage) is present on admission

Non-Pressure Ulcers

• Site:
    --Back
    --Buttock
    --Lower limb
       °°Laterality
           »»Right
           »»Left
       °°Specific site/area
           »»Ankle
           »»Calf
           »»Heel/midfoot
               * Plantar surface
           »»Thigh
           »»Other part of lower leg
    --Other (specify)
• Ulcer depth:
    --Limited to skin breakdown
    --With fat layer exposed
    --With muscle necrosis
    --With bone necrosis
• Cause of lower limb ulcers:
    --Atherosclerosis of lower extremity
    --Chronic venous hypertension
    --Diabetic ulcer
    --Postphlebitic syndrome
    --Postthrombotic syndrome
    --Varicose ulcer
    --Other (specify)
• With gangrene
• Document any associated diagnoses/conditions

Asthma, Crohn’s Disease/Regional Enteritis and Appendicitis

Asthma

Asthma

 

• With
    --Acute lower respiratory infection
    --COPD
    --Chronic obstructive bronchitis
    --Exacerbation
    --Status asthmaticus
• Severity
    --Mild intermittent
    --Mild persistent
    --Moderate persistent
    --Severe persistent
• Form or Type
    --Cough variant
    --Childhood
    --Exercise induced bronchospasm
    --Extrinsic allergic
    --Idiosyncratic
    --Intrinsic nonallergic
    --Late-onset
    --Mixed
    --Other (specify)
• Document any associated diagnoses/conditions

Crohn’s Disease/Regional Enteritis

• With Complication
    --Abscess
    --Fistula
    --Intestinal obstruction
    --Rectal bleeding
    --Other (specify)
• Site
    --Small intestine
    --Large intestine
    --Both small and large intestines
• Document any associated diagnoses/conditions

Appendicitis

• Severity
    --Acute
    --Chronic
    --Recurrent
    --Subacute
• With
    --Perforated or ruptured appendix
    --Peritoneal abscess
    --Peritonitis
       °°Generalized
       °°Localized
    --Other (specify)

Cardiac Arrest, Pneumonia and Respiratory Failure

Cardiac Arrest

Cardiac Arrest

 

• When there is a “Cardiac Arrest” the documentation should include:
    --due to underlying cardiac condition
    --due to other underlying condition
    --cardiac arrest, cause unspecified
• In addition, specify if:
    --postprocedural cardiac arrest following cardiac surgery
    --postprocedural cardiac arrest following other surgery
    --intraoperative cardiac arrest during cardiac surgery
    --intraoperative cardiac arrest during other surgery
• Always document the “underlying cardiac condition” if known
• Document any associated diagnoses/conditions

Pneumonia

• Document causative organism (if known)
• Document mechanism:
    --Aspiration
    --Ventilator-associated
    --Radiation-induced
    --Other (specify)
• Document any associated illness:
    --Respiratory failure
    --Sepsis
    --Underlying lung disease
    --Other (specify)
• Document history of tobacco use—present or past

Respiratory Failure

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• Document acuity:
    --Acute
    --Chronic
    --Acute on chronic
• Document inclusion of:
    --Hypoxia
    --Hypercapnia
• Document tobacco:
    --Use
    --Abuse
    --History of
• Document any associated diagnoses/conditions

Heart Failure, CVA and Myocardial Infarction Documentation

Heart Failure

Heart Failure

• Document acuity
    --Acute
    --Chronic
    --Acute on Chronic
• Document type
    --Diastolic
    --Systolic
    --Combined systolic and diastolic
• Due to or associated with
    --Cardiac or other surgery
    --Hypertension
    --Valvular disease
    --Rheumatic heart disease
       °°Endocarditis (valvitis)
       °°Pericarditis
       °°Myocarditis
    --Other (specify)

CVA

• Due to Hemorrhage
    --Location or source of hemorrhage
       °°Subarachnoid (specify artery, if known)
       °°Intracerebral (specify location, if known)
       °°Intracranial
          »»Subdural
              * Acute, Subacute, Chronic
          »»Extradural
    --Laterality
    --Document any associated diagnoses/conditions
• Due to causes other than hemorrhage
    --Cause
       °°Thrombosis
       °°Embolism
       °°Other (specify)
       °°Unspecified Occlusion or stenosis
    --Site
       °°Precerebral Arteries (specify artery, if known)
       °°Cerebral Arteries (specify artery, if known)
    --Laterality
    --Document any associated diagnoses/conditions

Myocardial Infarction

• Document the type of MI:
    --ST elevation (STEMI)
       °°Requires site and specific artery:
           »»Anterior Wall
               * Left main coronary artery
               * Left anterior descending artery
               * Other coronary artery of anterior wall
           »»Inferior Wall
               * Right coronary artery
              * Other coronary artery of inferior wall
    --Other
       °°Left circumflex coronary artery
       °°Other Specified
    --Non-ST elevation MI (NSTEMI)
       °°Requires episode of care reporting only
• Document date of any recent acute MIs within 28 days of admission
• Document whether or not the current MI has occurred within 28 days
of a previous MI
• Document if the patient has a history of an MI (older than 28 days)
• Document any associated diagnoses/conditions

Glaucoma, Otitis Media and Hearing Loss Clinical Documentation

Glaucoma

Glaucoma

• Type (specify eye(s) affected)
    --Open angle
    --specific type (primary, low-tension, pigmentary, capsular, residual
       stage)
    --Narrow angle (angle-closure)
    --specific type (e.g. acute, chronic, intermittent, residual stage),
    --Glaucoma in diseases, such as:
    --Amyloidosis
    --Diabetes
    --Other (specify)
    --Glaucoma suspected
• Secondary glaucoma due to:
    --Drugs
    --Eye inflammation
    --Trauma
    --Other disorders
• Stage (specify eye(s) affected)
    --Mild
    --Moderate
    --Severe, Advanced, End-stage
    --Indeterminate
• Document any associated diagnoses/conditions

Otitis Media

• Incidence:
    --Acute/subacute
    --Acute recurrent
    --Chronic
• Laterality:
    --Right ear
    --Left ear
    --Bilateral
• Types:
• Serous
• Suppurative or Nonsuppurative
• Tubotympanic
• Atticoantral
• Allergic
• Mucoid
• Document if associated with:
    --Spontaneous rupture of tympanic membrane
    --Without spontaneous rupture of tympanic membrane
    --Infectious or other external agent
    --Exposure to environmental tobacco smoke
• Document any other associated diagnoses/conditions

Hearing Loss

• Laterality:
    --Bilateral
    --Unilateral
• Extent of hearing loss:
    --Left/right ear with unrestricted hearing on the contralateral side
• Types:
    --Conductive
    --Sensorineural
    --Mixed
    --Other (specify)
• Document any associated diagnoses/conditions

Cerebral Palsy, Depressive and Altered Mental Status

Cerebral Palsy

             

                                                          Cerebral Palsy

 

• Document presence of spasticity
• Document type:
    --Quadriplegic, Diplegic, Hemiplegic, etc.
    --Ataxic
    --Athetoid
    --Choreathetoid
    --Dyskinetic
    --Dystonic
    --Mixed
    --Syphilitic
• Document any associated diagnoses/conditions

Depressive

• Document episode:
    --Single
    --Recurrent
• Document severity:
    --Mild
    --Moderate
    --Severe
    --With psychotic features
    --Without psychotic features
• In partial or full remission (if applicable)
• Document any associated diagnoses/conditions

Altered Mental Status

Document the etiology of the altered mental status as:
    --Coma
    --Confusion/delirium (including drug-induced)
    --Drowsiness/somnolence
    --Stupor/semi-coma
    --Transient alteration of awareness
    --Encephalopathy
    --Alcoholic
    --Anoxic/hypoxic
    --Drug-induced/toxic (specify drug)
    --Hepatic
    --Hypertensive
    --Hypoglycemic
    --Metabolic/septic
    --Traumatic/post-concussion
    --Wernicke
    --Other (specify)
• Document any associated diagnoses/conditions

Obesity, Malnutrition, Alcohol, Tobacco and Substance

Obesity

 

• Obesity
    --Morbid (severe)
    --Due to excess calories
    --With alveolar hypoventilation (Pickwickian syndrome)
    --Drug Induced
    --Document drug
    --Other
    --Due to excess calories, familial, endocrine
• Overweight
• Body Mass Index (BMI)
• Document any associated diagnoses/conditions

Malnutrition

• Severity:
    --Mild (first degree)
    --Moderate (second degree)
    --Severe (third degree)
• Avoid documenting a range of severity, such as “moderate to severe”
• Form:
    --Kwashiorkor (rarely seen in the U.S.)
    --Marasmus
    --Marasmic kwashiorkor
    --Other
• Document any associated diagnoses/conditions

Alcohol, Tobacco, and Substance Use

• Identify the specific type of drug or substance
• Describe the frequency of usage as:
    --Use
    --Abuse
    --Dependence
    --In remission
• Describe mode of nicotine use as cigarettes, chewing tobacco, pipe,
and/or gum
• Specify intoxication/withdrawal as “Uncomplicated” or “With delirium”
• Document any withdrawal symptoms
• Document any associated diagnoses/conditions
• List the blood alcohol level, if available
• State “no related complications,” when applicable
• Document any related mood disorder
• Document any delusions, hallucinations, anxiety, sleep disorders, sexual
dysfunctions, or other related conditions
• List any treatment provided:
    --Detoxification services
    --Counseling
    --Psychotherapy
    --Medication management

Diabetes, Coagulopathy and Purpura Clinical Documentation

Diabetes

Main Symptoms Of Diabetes

 

• Type:
    --Type 1
    --Type 2
    --Drug/chemical induced
    --Due to underlying condition
    --Other specified type
• Control:
    --Inadequate control
    --Out of control
    --Poorly Controlled
    --Hypoglycemia
    --Hyperglycemia
• Insulin use
• Document any associated diagnoses/conditions
• Manifestation/Complication (document link to diabetes)
    --Circulatory complications
    --Hyperosmolarity
    --With or without coma
    --Hypoglycemia
    --Ketoacidosis
    --With or without coma
    --Kidney complications
    --Neurological complications
    --Ophthalmic complications
    --Oral complications
    --Skin complications
    --Arthropathy
    --Other (specify)

Coagulopathy

• Specify type:
    --Disseminated intravascular coagulation
    --Hereditary factor VIII deficiency
    --Hereditary factor IX deficiency
    --Von Willebrand’s disease
    --Hereditary factor XI deficiency
    --Hereditary deficiency of other clotting factors
    --Acquired coagulation factor deficiency
    --Primary thrombophilia
    --Activated protein C resistance
    --Prothrombin gene mutation
    --Other primary thrombophilia
    --Other thrombophilia
    --Antiphospholipid syndrome
    --Lupus anticoagulant syndrome
    --Other Specified coagulation defects
• Document any associated diagnoses/conditions
• Hemorrhagic disorder due to circulating anticoagulants
    --Due to intrinsic circulating anticoagulants, antibodies, or inhibitors
    --Acquired hemophilia
    --Antiphospholipid antibody with hemorrhagic disorder
    --Other hemorrhagic disorder due to intrinsic circulating
anticoagulants, antibodies, or inhibitors
    --Hemorrhagic disorder due to extrinsic circulating anticoagulants
    --Document specific drug, if drug-induced

Purpura

• Specify if “Allergic purpura” is present and note the following:
    --Allergic vasculitis
    --Nonthrombocytopenic hemorrhagic purpura
    --Nonthrombocytopenic idiopathic purpura
    --Purpura anaphyloctoid
    --Purpura Henochi
    --Purpura rheumatica
    --Vascular purpura
• Document if “Qualitative platelet defects” is present
• Specify if “Other nonthrombocytopenic purpura” is present
    --Purpura not otherwise specified
• Document if any of the following are present:
    -- “Immune thrombocytopenic purpura”
    --“Other primary thrombocytopenia”
    --Evans Syndrome
    --Congenital and/or Hereditary thrombocytopenia
    --“Secondary thrombocytopenia”
    --Posttransfusion pupura
    --Other secondary thrombocytopenia
• Document “Other specified hemorrhagic conditions”
    --Capillary fragility (hereditary)
    --Vascular pseudohemophilia
• Document any associated diagnoses/conditions

Pancytopenia, Nutritional and Aplastic Anemia Clinical Documentation

Pancytopenia

Pancytopenia

 

• Specify if:
    --Antineoplastic chemotherapy induced pancytopenia
    --Other drug-induced pancytopenia
    --Specify drug
    --Other pancytopenia
• Specify the etiology of pancytopenia (if known), such as:
    --Myelodysplastic Syndrome
    --Leukemia
    --HIV
    --Other (specify)
• Document any associated diagnoses/conditions

 

Nutritional Anemia

 • Iron deficiency anemia

• Iron deficiency anemia secondary to blood loss
    --Acute blood loss anemia
    --Chronic blood loss anemia
• Iron deficiency anemia due to poor iron absorption
• Vitamin B12 deficiency
    --Pernicious anemia
    --Malabsorption with proteinuria
    --Transcobalamin II deficiency
    --Vegan Anemia
• Document Folate deficiency anemia
    --Dietary induced
    --Drug-induced
• “Protein” deficiency anemia
• “Megaloblastic” anemia
• List all secondary comorbidities and complications
• Document any associated diagnoses/conditions

Aplastic Anemia

For aplastic anemia and other bone marrow failure syndromes:
    --Specify if “Acquired pure red cell aplasia”
    --Chronic
    --Transient
    --Other
    --Specify if aplastic anemia is:
    --Constitutional
»»Congenital, idiopathic or acquired
    --Drug-induced, radiation, or induced from other external agent
    --Idiopathic
    --Document pancytopenia or myelophthisis, if also present
• Document if any of the following are present:
    -- “Acute posthemorrhagic anemia”
    --“Anemia in neoplastic disease”
    --“Anemia in chronic kidney disease”
    --“Anemia in other chronic disease”
    --List the chronic diseases
• Document if “Sideroblastic anemia” is:
    --Hereditary
    --Secondary due to disease
    --Secondary due to “drugs and toxins”
    --Congenital dyserythropoietic anemia
• Document if the Anemia is Due to Antineoplastic chemotherapy
• Document any associated diagnoses/conditions