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Wiki Anemia and Chemo

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mdixon2

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I am trying to code an ED chart. The patient was diagnosed with s/p chemotherapy and anemia. They physician documented it this way "chemotherapy-- anemia. My question is this enough to code anemia due to chemo or must the physician actually state it was due to the chemo. Any feedback and resources would be greatly appreciated.
 
sande78705 said:
More than likely the anemia was a result of the patient's chemo therapy and you would use the 284.11
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284.11 is antineoplastic chemotherapy induced pancytopenia.
285.3 is antineoplastic chemotherapy induced anemia.

I see what mdixon is referring to and I'd feel more confident if the physician were more specific.

On the fence but leaning toward 285.9
 
The physician's documentation is insufficient to provide causality. We, as coders, are not allowed to infer such a relationship for this situation. There are situations (like diabetes) where causality can be assumed and coded. I would code 285.9.

If the physician's note stated something like "anemia due to chemotherapy" or "chemotherapy induced anemia", then I would code 285.3.

Alanna, CPC, CHONC
 
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