The Gastrointestinal Bleed Conundrum: To Code “with bleed” or Not?

By Tina Bruce, MSHIM, MSHI, RHIA, CCS, CDIP

How to code gastrointestinal conditions with or without bleeding has been a topic of discussion among coding professionals and clinical documentation improvement professionals since the publication of the third quarter 2017 issue of the American Hospital Association’s Coding Clinic. Coding Clinic advised coders to apply the “With” guideline associating bleeding to the gastrointestinal condition even when the medical record lacks a causal relationship documented by the physician. The conundrum with coding gastrointestinal bleeds seems to occur most often when the patient’s presenting symptoms lack the supporting physician’s documentation of gastrointestinal-related diagnoses.

For example, say the patient presented with a history of melena one month ago. An esophagogastroduodenoscopy (EGD) was performed and the provider’s final impression in the report states: Grade D esophagitis and acute gastritis with no evidence of related current or recent bleeding. Many coders and CDI experts overlook that this documentation indicates that the esophagitis and acute gastritis are not the underlying causes for the patient’s melena. The important thing to remember per the advice published in Coding Clinic, Third Quarter 2017 and 2018 is that the examples provided in these issues direct the coding professional to assume the causal relationship between the GI condition and GI bleed unless the provider states it is NOT the cause.

According to the guideline I.A.15. “With” from the ICD-10-CM Official Guidelines for Coding and Reporting, these conditions should be interpreted to mean “associated with” or “due to” when it appears in the code title UNLESS the provider documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between the two conditions. For example, for sepsis due a postprocedural infection, the ICD-10-CM coding guidelines state, “code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.”

The American Hospital Association Central Office has received questions related to coding acute gastritis with bleeding and addressed this scenario in Coding Clinic third quarter 2017 on page 27.

The things that should be considered when coding gastrointestinal conditions “with” or “without” bleeding are physician documentation and appropriately interpreting the ICD-10-CM Official Guidelines for Coding and Reporting. If the provider states that the GI bleeding present is unrelated to a current GI condition, coding and CDI professionals should not code these conditions as related and therefore the “with” subterm in the alphabetic index path does not apply. The presence of this documentation found within a patient’s record supports that the bleeding is unrelated to the gastrointestinal conditions and should not be coded “with bleeding.”

Coding and CDI professionals will always be faced with daily coding challenges. They need to remember the many helpful coding resources and references that are available to help in answering their complex coding questions. Questions can be sent to the American Hospital Association’s Coding Clinic. AHIMA’s Engage communities often have coding professionals that have encountered similar situations, and AHIMA’s Code-Check® service are just a few great resources that can be utilized for expert advice.

References

American Hospital Association. AHA Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018, pages 22-23.