Anemia ICD 10

In this topic will discuss about Anemia, types of Anemia and Anemia ICD 10 coding guidelines along with examples.

Anemia:

In simple words, anemia is lack of Red Blood Cells(RBC). It has got a protein called hemoglobin in it which carries and delivers oxygen to our body organs. So low RBC leads to low hemoglobin and this affects other organ’s function due to less oxygen. Anemia can be for a shorter period or longer period, can be mild or severe. Anemia can occur due to many reasons such as blood loss, any other disease, during pregnancy, nutrition deficiency, drug induced and many more. So, there are plenty of Anemia ICD 10 codes and will discuss later on the same.

Types of Anemia:

We will see few types of anemia which are frequently seen in medical records.

Iron deficiency anemia –Iron is needed in blood to make hemoglobin. Iron deficiency anemia occurs when there is very low amount of iron in blood. Mostly this can happen in woman due to heavy menstruation.

Sickle cell anemia – It is a genetic disease in which the RBC changes to crescent shape resembling a sickle. This makes RBC difficult to travel in the blood vessels. They are not healthy enough to carry oxygen to our body organs.

Vitamin deficiency anemia – As the name says deficiency of vitamins like folate, B12, C leads to deficiency of healthy RBCs and anemia.

Blood loss anemia – One can become anemic due to severe blood loss. Once the cause is corrected that person becomes normal. This is termed as acute blood loss anemia. But sometimes, for example, in case of stomach ulcers, occult blood can happen for a long time. This chronic blood loss can lead to anemia which is called chronic blood loss anemia.

Symptoms and diagnosis:

All types of anemia has similar symptoms like dizziness, pale skin, light-headedness, fast heart beat, shortness of breath.

As a part of confirming the diagnosis doctor may ask your personal and family history and also do a Physical exam and blood test CBC (complete blood count).

Anemia ICD 10 Codes and guidelines:

ICD-10 CM manual Chapter 3(diseases of blood & blood forming organs & disorders involving immune mechanism, code range D50 – D89) will be expanded further. As anemia ICD 10 codes are overlapped with other conditions, hence we can find anemia ICD 10 coding guidelines in other chapters also.

There are plenty of ICD 10 codes for anemia depending on the cause. As it is not possible to mention all the codes here, just given a screenshot below on how to search the code through ICD-10 CM manual index.

There are specific guidelines to code anemia when it is incorporating with another disease. We need to use specific ICD 10 code as per the reason of anemia and sequence correctly. In such cases, it is important to have clear documentation in the medical record regarding the reason for anemia. Coder may query the provider if the reason is not specified. We will see the Anemia ICD 10 guidelines with example.

1) Anemia with malignant neoplasm:

Correct code should be assigned as per the reason of anemia whether it is due to neoplasm or chemotherapy. Neoplasm should be coded primary if the anemia is due to neoplasm. Anemia should go primary if it is due to chemotherapy.

These are the 2 ICD codes comes with this scenario.

D64.81- Anemia due to antineoplastic chemotherapy

D63.0 –Anemia in neoplastic disease

Anemia ICD 10 (Anemia with malignant neoplasm ICD 10) Example 1

70 year old Andrea has come to oncologist for a follow up of her anemia associated with neoplasm. She feels dizziness frequently. She is undergoing chemotherapy for her right breast cancer. Her past medical history includes COPD and hypertension. Her medication list was reviewed which includes Albuterol, atenolol, anastrozole.

Physical exam mentioned as alert and oriented, skin looks pale, tachycardia. BP noted as 100/60 mmHg. Hemoglobin level today is 6.0 g/dL. Oncologist listed diagnosis ‘anemia due to neoplasm’

Following Anemia ICD 10 codes should be reported:

C50.911 – Malignant neoplasm (Right breast)
D63.0 – Anemia in neoplastic disease
I10 – Hypertension
J44.9- COPD

Note : Here neoplasm should be coded primary as per the code first note with D63.0

Anemia ICD 10 (Anemia with malignant neoplasm ICD 10) Example 2

John, 55 year old male comes to hospital with her son for extreme weakness and dizziness started after his first cycle of chemotherapy for prostate cancer. No significant past medical history noted. He is a cigarette smoker, use 3 packets daily.

Vitals noted low BP 80/50 mmHg. Physical exam noted for muscle weakness, coldness on skin, slight yellow eyes. Hemoglobin noted as 7.0 g/dL. Physician has documented final assessment “anemia due to chemotherapy”

Following Anemia ICD 10 codes should be reported:

D64.81 – Anemia due to chemotherapy treatment
C61 – Malignant neoplasm (Prostate)
T45.1X5A–Adverse effect of antineoplastic drugs
F17.210–Nicotine dependence, cigarette.

Note : Here ICD for anemia goes primary.

2) Anemia in chronic diseases

Guideline to be used here is “code first underlying cause”.

ICD-10 codes for anemia with this scenario are given below.

D63.1 – Anemia in Chronic Kidney Disease(CKD)

D63.8 – Anemia in other chronic diseases

Anemia ICD 10 (Anemia in Chronic diseases ICD 10) Example:

Ms. Smith, 68 year old female admitted to hospital with anemia due to ESRD. Today is her second day in hospital. She has an AV fistula done for hemodialysis. Medications are continuing for diabetes and hypothyroidism. Today her BP is 100/60mmHg. Her skin is warm, weakness is improved. Hemoglobinis7.5 g/dL today.

Following Anemia ICD 10 codes should be reported:

N18.6 – ESRD
D63.1 – Anemia in CKD
E11.22 – Type II DM with CKD
E03.9 – Hypothyroidism
Z99.2 – Dependence on hemodialysis

Note : ESRD is coded primary as that is the underlying cause for anemia. Also, as per“code first” note with ICD D63.1

3) Anemia in pregnancy and postpartum

Below are the codes to be noted in this category.

O99.011 – O99.019–Anemia complicating pregnancy – Choose the code as per trimester.

O99.02 –Anemia complicating childbirth – When delivery is completed by anemia.

O90.81 – Postpartum Anemia, this is applicable only in case of anemia not pre-existing prior to delivery

O99.03 –pre-existing anemia complicating puerperium

Anemia ICD 10 (Anemia in Pregnancy & Postpartum ICD 10) Example:

Patricia, 25 year old lady is admitted for delivery. She has no pre-existing conditions which complicates delivery. After delivery the physician documented in the medical record “obstetric patient delivered with anemia”, single live born.

Following Anemia ICD 10 codes should be reported:

O99.02 – Anemia complicating childbirth
Z37.0 – Single live birth

Note : It is not necessary to code D64.9 (anemia, unspecified) here as it is unspecified anemia.

4) New born Anemia

Codes from this category should be coded in the baby’s medical record, not in mother’s. Medical record should be clearly verified to confirm if the anemia is congenital or not, and if congenital the reason also needed.

P61.2 – Anemia of prematurity

P61.3 – Congenital anemia in new born babies as a result of intra uterine blood loss during delivery.

P61.4 – Congenital anemia caused by any other reason other than intra uterine blood loss.

Anemia ICD 10 (New born Anemia ICD 10) Example:

30 year old Emma is admitted to hospital for delivery. Heavy intrauterine bleeding occurred during delivery. Baby was born with hemoglobin 8.0 g/dL. Physician documented in the baby’s record “anemia due to heavy bleeding”.

Following Anemia ICD 10 codes should be reported for this baby’s record: