Continuing our series of blogs highlighting some of the most common coding errors encountered while auditing.

In my experience it is rare for a physician to document "The cause for the GI bleeding is <fill in the blank>". Typically, there is an EGD or a colonoscopy report that contains the phrase: "no stigmata of recent bleeding" or "no active bleeding" but does not usually document: "the GI bleeding was caused by <fill in the blank>.” However, if any non-specific terms such as "gastrointestinal (GI) bleeding", "melena", "hematochezia", or "rectal bleeding" are documented without a definitive source diagnosed by the physician, then all the other conditions documented as part of the patient's current condition that meet the guideline and have "with" or "in" bleeding indexed in the coding book should be coded. Depending on the circumstances of admission and treatment, one of these might take precedence as the principle diagnosis. The key point to remember is to that all the appropriate conditions are coded as "with bleeding" which can potentially create a CC or an MCC and/or affect the DRG.

From Chapter 19 in the current coding guidelines: 
"As stated in Section I. A. 15 of the Official Coding Guidelines, the classification presumes a causal relationship between the two conditions linked by the terms "with" or "in" in the Alphabetic Index or Tabular List. ICD-10-CM provides such a linkage for bleeding with certain GI conditions such as ulcers, gastritis, duodenitis, ulcerative esophagitis, and diverticulosis. Unless the provider documents a different cause of the bleeding or states that the conditions are unrelated, it is appropriate to report the combination code for these conditions."

Also, remember that not all conditions that can possibly cause GI bleeding have the term "with bleeding" in the wording of the code or are indexed as such in the coding book. An example is hemorrhoids which has the term "with complication", and "bleeding" indexed but not "with bleeding". In this case, the hemorrhoid would have to be specified as "bleeding" in order to code it as such. Though "gastritis" does have the indexed term "with bleeding", "esophagitis" does not, so there is not a presumed relationship for the esophagitis.

In order to code only one cause for a GI bleed, be sure the documentation indicates a specific cause for the bleeding, which would ideally be "the one and only cause for the GI bleeding was <fill in the blank>.” If the physician is specific about the cause, then only that condition that has a "with bleeding" code is required. If there are other diagnoses documented that could be indexed as "with bleeding", those would not be coded as such since a definitive cause is documented. An example would be if the physician states the patient's GI bleeding is caused by a gastric ulcer, but there was also diverticulosis of the colon noted. Only the gastric ulcer would be coded as "with bleeding" unless the diverticulosis was stated as a cause of bleeding as well.

If one or more of these types of diagnoses are documented along with the non-specific term such as "melena", do not code the non-specific term in addition to the other diagnoses. "GI bleeding", "melena", etc. are only coded if there are no other related diagnoses.

I hope this assists you in coding gastrointestinal bleeding more accurately.

Hobert Hampton, RHIT, CCS
Quality Assurance Analyst