Coding corner: How to handle coagulopathy

Coagulopathy can be challenging for coding professionals, specifically for patients with a current bleed being treated with an anticoagulant or antithrombotic for a separately diagnosed condition.

In ICD-9-CM, this scenario required the location of the bleeding to be coded, followed by the adverse effect of the anticoagulant or antithrombotic drug code.

In ICD-10-CM, coagulopathy is still represented by two codes, but the site of occurrence may not be required; it depends on the circumstances of the encounter. According to the first quarter 2016 Coding Clinic release, the appropriate ICD-10-CM code assignment for this scenario would be D68.32, hemorrhagic disorder due to extrinsic circulating anticoagulant, along with the appropriate adverse effect code for the drug. Support is in the inclusion terms for code D68.32, which state “drug-induced hemorrhagic disorder.”

Most codes in category D68 — other coagulation defects — are generally assigned for hemorrhagic disorders or coagulation defects and must be specifically stated and documented by the patient provider. But code D68.32 is unique to this category: It’s the only code pertaining to extrinsic factors, relating to a process within the body due to provocation, specifically anticoagulants.

Anticoagulant therapies are divided into four classes, depending on the mechanism of action:

• Vitamin K antagonists
• Warfarin (Coumadin, Jantoven)
• Low molecular weight heparins and heparin
• Enoxaparin (Lovenox)
• Dalteparin (Fragmin)
• Thrombin inhibitors
• Bivalirudin (Angiomax)
• Argatroban (Acova)
• Dabigatran (Pradaxa)
• Antithrombin III (Thrombate III)
• Factor Xa inhibitors
• Apixaban (Eliquis)
• Fondaparinux (Arixtra)
• Rivaroxaban (Xarelto)
• Edoxaban (Savaysa)

We can’t assign this code to any patient on an anticoagulant with a prothrombin time and international normalized ratio or partial thromboplastin time that’s outside the therapeutic range. This code description refers to a “hemorrhagic disorder,” which, according to the Coding Clinic, includes bleeding such as:

• Hemoptysis
• Hematuria
• Hematemesis
• Hematochezia

In addition, an inclusion term for this code also includes hyperheparinemia, or excessive heparin in the blood.

Provider documentation must support the causal relationship between the bleed and the anticoagulation therapy. The Coding Clinic says, “An increased risk for bleeding is a side effect associated with anticoagulant therapy. The adverse effect code is assigned for bleeding resulting from an anticoagulant that is properly administered.” Code D68.32 includes a “use additional code” note to remind us to code the adverse effect (if applicable) to identify which drug the patient is taking, and thus causing the condition.