Acute Blood Loss Anemia (D62): In Denials, Not All Literature is Created EqualClarissa Barnes, MD, FACP Anyone who works clinical validity denials knows that there are some diagnoses that seem to crop up over and over again. One of my favorite “habitual offenders” in the realm of frequently denied diagnoses is Acute Blood Loss Anemia (ABLA), also known as acute post hemorrhagic anemia. The reasons insurance companies and other payers cite to deny can be variable, but lately there has been a concerning trend of using scientific and medical literature inappropriately to deny valid ABLA diagnoses. It can be intimidating when you receive a denial with multiple citations explaining why this patient does not have anemia and therefore cannot have Acute Blood Loss Anemia. However, when validating a diagnosis, not all literature (no matter how great the source) should be equally weighed. What is considered to be “enough” blood loss to qualify for ABLA has sometimes been a debate. Personally, I subscribe to the very precise definition of “it depends on the clinical scenario.” In the right context, 1-2 g/dl is plenty, especially when the patient is already starting from a lower value. A 1g/dl change is often cited as not significant enough to be a true drop, but the patient acutely bleeding who just went from 8 g/dl to 7 g/dl (and therefore just lost 12.5% of his/her blood) would beg to differ. While there is room to discuss and debate how much blood loss is enough, what constitutes anemia has generally been accepted as standard. The World Health Organization’s definition of anemia is specific to gender and gravid status. Specifically the definition of anemia is:
(If you’re looking for some great additional CDI resources on ABLA and other diagnoses, check out the Clinical Documentation Committee page on the ACPA website here.) ABLA is often the only CC on a chart and can look like an easy target for payer denial. After all, removing the only CC moves the DRG and decreases what they need to pay. Unfortunately, there appears to be an emerging trend to deny the diagnosis of ABLA citing sources with different criteria for anemia. After all, you cannot have ABLA without anemia, right? (If the lowest value does not reach a threshold for anemia, then you have R71.0, precipitous drop in hematocrit). The most egregious attempt to discredit ABLA by arguing the definition of anemia is by using the citation of the Common Terminology Criteria for Adverse Events (CTCAE) which indicates that anemia is defined as a hemoglobin of 10 or less. (1) Using the CTCAE to negate the diagnosis of ABLA is inappropriate since this definition of anemia is not meant to be applied to the general population. These criteria are to clarify what is considered an adverse event in patients using therapies for cancer. “These criteria are used for the management of chemotherapy administration and dosing, and in clinical trials to provide standardization and consistency in the definition of treatment-related toxicity.” (2) In other words, this definition is strictly to clarify and track possible adverse events related to chemotherapy and is not meant to be used to define anemia for patients with acute blood loss. The other, albeit less common, strategy is to try to use the more restrictive WHO definition with a hemoglobin level of less than 11 g/dl (meant for pregnant patients) in non-pregnant patients. This is obviously also not correct since there are separate definitions for non-pregnant people for a reason. Both of these strategies use literature that is scientifically accepted (whether it’s using the CTCAE or the WHO) but in an improper way. Do not get caught off-guard by the source of the citation but take the time to find out what the scope of evidence is. A winning appeal in this scenario explains not only why the WHO definition is correct, but also why the other definitions are wrong. Citations:
Dr Barnes is system physician advisor for UR and CDI at Avera Health. |