A Question a Day will Keep the Queries Away: Acute Blood Loss Anemia

I conceived a new project that triggered last week’s TalkBack segment on the Talk Ten Tuesdays weekly Internet radio broadcast, and I would love your feedback on the concept.

My vision is to design a comprehensive clinical documentation improvement (CDI) curriculum and teach it in small, digestible aliquots. There are three audiences: providers, CDI professionals, and coders, and I want to teach them in parallel. I want the physicians to know what the CDI specialists (CDISs) and coders need from them, and I want the CDISs and coders to understand the medicine and how to get their clinicians to document it properly. Everyone will be on the same page and know what the others want and need. The information will be delivered in the form of a question a day, with CMEs and CEUs available for a reasonable price. Let me know what you think of the idea.

My first subject was COVID-19, my current pet project. I have now dug in on pedestrian CDI topics, and the first one alphabetically was acute blood loss anemia. My listeners and readers seem to like when I address clinical topics with them, so I decided to share some factoids and thoughts with them as the project progresses. Dr. Ronald Hirsch affectionately warned our listeners: nerd alert! And I will assert that here as well.

Acute blood loss anemia is our nickname for acute post-hemorrhagic anemia, the title of the ICD-10-CM code, D62. We often refer to it with the acronym ABLA. Why is losing blood so impactful?

Hemoglobin A is the protein in red blood cells responsible for transporting oxygen. It is a complicated molecule composed of four folded subunits, two alpha and two beta chains, each with an incorporated heme group composed of an organic ring-like compound called porphyrin oriented around a central iron atom. The iron atoms reversibly bind to oxygen. The major functions of red blood cells are to deliver oxygen to tissues, and to extract carbon dioxide.

The hematocrit is the proportion, by volume, of blood that consists of red blood cells. It is expressed as a percentage. If the hematocrit is 40 percent, it means that when the blood is spun down, 40 percent of the volume is red blood cells and 60 percent is serum.

There are varying normal ranges for hemoglobin and hematocrit, factoring in gender, age, race, and health factors, such as being an athlete, living at high altitude, being a smoker, or having chronic disease. For men, hemoglobin is usually somewhere between 13.5 and 17.5 g/dL, and for women, 12.0 to 15.5 g/dL. Hematocrit runs roughly three times the hemoglobin. Having too little hemoglobin or erythrocytes is defined as anemia; polycythemia is having more red blood cells than normal.

Different mechanisms can result in anemia, including blood loss, hemolysis (i.e., cell breakdown), and decreased production. If your hemoglobin falls below the lower end of the range, you are considered anemic. Moderate anemia corresponds to a level of 7.0 to 9.9 g/dL, whereas severe anemia is considered to be a level less than 7.0.

The most common cause of acute anemia in the emergency department is blood loss. If you lose blood, you lose blood cells, and ultimately, it impairs your ability to deliver oxygen to the tissues. Organs depend on oxygen to function properly, and massive hemorrhage is life-threatening.

The treatment of blood loss is determined by the rapidity by which the anemia develops, the degree of blood loss, whether symptoms have arisen, and whether there are high-risk clinical circumstances rendering the patient more vulnerable to harm. Providers need to learn to go through the hASSLe of giving the coders Acuity, Severity, Specificity, and Linkage.

There are no hard-and-fast rules as to what the drop in hemoglobin or hematocrit must be to diagnose ABLA. When institutions ask me for help drafting internal guidelines, I suggest a drop of around 2g of Hgb, and some literature also uses a percentage drop of hemoglobin (not hematocrit) of 15-20 percent. It is not incontrovertible; clinical judgment must be exercised.

Treatment may involve blood transfusion, but not always. Transfusions have associated risk, so most practitioners reserve them for severe anemia and/or clinical situations that make anemia riskier, like tenuous coronary artery disease. Iron supplementation or careful monitoring may be the extent of treatment. ABLA is clinically significant because it enters into the provider’s calculus of care and increases risk.

What isn’t ABLA?

If the provider thinks the drop in hematocrit is due to hemodilution, they should document that. Since hematocrit is volume-dependent, if the patient receives significant fluid resuscitation, it can dilute the blood and lower the red blood cell volume. If the patient’s kidney function is normal, passage of time will allow for elimination of excess fluid and equilibration. If the clinician documents their thought process and explains their actions (or lack of action, in this case), I advise them they will ward off a query.

There is another codeable condition called precipitous drop in hematocrit, R71.0. This term can indicate several situations. In the first scenario, there is acute blood loss, but the patient never falls into anemic territory; therefore, acute blood loss anemia is not the appropriate term. In another situation, there is an acute drop in hematocrit, but it is not clearly from hemorrhage, and the cause is yet to be identified. There are other mechanisms through which a patient can become anemic, aside from acute blood loss. R71.0, Precipitous drop in hematocrit, is a complication or comorbidity (CC), just as ABLA is.

Another important point to bring all parties together on the same page is that ABLA is not a patient safety indicator (PSI). Perioperative hemorrhage or hematoma may be a PSI, and ABLA may accompany it, but ABLA is not a PSI on its own. Providers may be hesitant to document it because they are concerned they will be penalized. Clinicians need to understand that if resources to manage ABLA are consumed, the condition should be documented and catalogued.

Some questions raised will be case-based, but here is a sample question regarding ABLA:

1. Which of the following statements is false regarding acute blood loss anemia (ABLA)?

• It will trigger a quality measure PSI regarding hemorrhage
• There is no absolute value of level of hemoglobin drop that defines ABLA
• It occurs as a result of hemorrhage
• If a blood transfusion is necessary due to hemorrhage, acute blood loss anemia is likely present and should be documented

The explanation details why a. is the “correct” answer (false), as well as expounding on why the other choices are true. There are references provided so the adult learner can investigate in more depth, if they so desire.

So, what do you think? Do you like the concept? If you are hospital-based, would your administration think it was a valuable tool to get the providers, CDISs, and coders educated and aligned? Email me at icd10md@outlook.com and let me know.