Blood transfusions (taking blood from a healthy person and giving it to someone else) are performed routinely throughout the United States and are lifesaving procedures for thousands of patients with a variety of different conditions. Some people only need blood transfusions occasionally, such as when their hemoglobin level is too low. Other patients need regular blood transfusions over a long period of time. There are a variety of transfusion reactions that may potentially be a serious problem for patients in either group. Effective Oct. 1, 2010, new ICD-9-CM diagnosis codes will be available to appropriately classify various types of transfusion reactions.
Hemochromatosis
- 275.02 Hemochromatosis due to repeated red blood cell transfusions
Hemochromatosis is an excessive accumulation of iron in the blood. Causes include a genetic predisposition (hereditary forms) or the secondary effects of a disease process requiring repeated red blood cell transfusions (acquired forms). Associated conditions that would require serial transfusions include myelodysplasia and certain anemias (e.g., sickle cell anemia). Signs and symptoms include darkening or “bronzing” of the skin, weakness and fatigue, heart palpitations, joint or abdominal pain, infertility, impotence, or cessation of menstruation.
Circulatory Overload
- 276.61 Transfusion associated circulatory overload (TACO)
TACO is a volume overload that occurs several hours after initiation of transfusion due to a rapid rate of transfusion or massive volumes of blood or blood products. Underlying cardiac or pulmonary pathology may exacerbate overload. Due to their relative physiologic sensitivity, infants and the elderly are at an increased risk for TACO, even though the transfusion volumes may be small in comparison with those of other patients. Signs and symptoms of TACO include acute respiratory distress (e.g., dyspnea, orthopnea), increased blood pressure, peripheral edema and pulmonary edema secondary to congestive heart failure during or within six hours of transfusion.
Purpura
- 287.41 Posttransfusion purpura (PTP)
PTP is a potentially fatal blood transfusion complication characterized by the sudden onset of severe thrombocytopenia. Signs and symptoms may include fever, chills, bronchospasm and cutaneous hemorrhaging. In the absence of prompt intervention, the patient may suffer a fatal hemorrhage. Onset occurs approximately 5 to 12 days following transfusion of blood components (e.g., whole blood, RBCs, plasma or platelets).This reaction is associated with the presence of antibodies produced by the body (alloantibodies) directed against the human platelet antigen (HPA) system (i.e., HPA-1a antigen), which destroys both the patient’s platelets and donor platelets, resulting in a rapid decline in circulating platelets (i.e., blood-clotting cells).
Febrile Reaction
- 780.66 Febrile nonhemolytic transfusion reaction (FNHTR)
FNHTR is a self-limiting responsive fever occurring 1 to 6 hours after blood transfusion, which may persist for 8 to 12 hours. The fever may be accompanied by further symptoms of headache, tachycardia, chills, rigors or minor dyspnea. Fever is the most common adverse blood transfusion reaction, occurring in approximately 3 to 4 percent of all transfusions. Recognition of FNHTR is important, however, as a febrile reaction may be an initial indication of a developing septic or hemolytic condition.
ABO, Rh, and Other Non-ABO Incompatibility Reactions
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999.60 ABO incompatibility reaction, unspecified
- 999.61 ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed
- 999.62 ABO incompatibility with acute hemolytic transfusion reaction
- 999.63 ABO incompatibility with delayed hemolytic transfusion reaction
- 999.69 Other ABO incompatibility reaction
- 999.70 Rh incompatibility reaction, unspecified
- 999.71 Rh incompatibility with hemolytic transfusion reaction not specified as acute or delayed
- 999.72 Rh incompatibility with acute hemolytic transfusion reaction
- 999.73 Rh incompatibility with delayed hemolytic transfusion reaction
- 999.74 Other Rh incompatibility reaction
- 999.75 Non-ABO incompatibility reaction, unspecified
- 999.76 Non-ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed
- 999.77 Non-ABO incompatibility with acute hemolytic transfusion reaction
- ·999.78 Non-ABO incompatibility with delayed hemolytic transfusion reaction
- 999.79 Other non-ABO incompatibility reaction
Hemolytic transfusion reactions (HTR) are potentially serious transfusion-related complications that are often attributed to preventable medical error, such as mislabeling or other mismatch. The severity of transfusion reaction depends on the type of transfusion and nature of incompatibility. Nonhemolytic transfusion reactions are generally benign in presentation, characterized by a spontaneously resolving fever and dyspnea. Acute hemolytic reactions are life-threatening medical emergencies that can rapidly result in acute renal failure, disseminated intravascular coagulation, multiorgan failure and shock. Hemolysis is a process of accelerated abnormal red blood cell (RBC) destruction, clinically characterized by fever, chills, dyspnea, urticaria and rigors. As a complication of transfusion, it is precipitated by an incompatibility between a blood donor and recipient. Incompatibility between blood types (ABO) and Rh factors (positive or negative) cause an immune system response whereby antibodies are created that destroy the transfused red blood cells (hemolysis). Presentation may be acute, within the immediate posttransfusion period, or delayed, manifesting from 24 hours to 28 days (1 month) following the transfusion. Signs of hemolysis upon laboratory tests include the presence of antibodies to RBC antigens, ABO or non-ABO incompatibility and hemoglobinuria.
Other and Unspecified Reactions
- 999.80 Transfusion reaction, unspecified
- 999.83 Hemolytic transfusion reaction, incompatibility unspecified
- 999.84 Acute hemolytic transfusion reaction, incompatibility unspecified
- 999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified
- 999.89 Other transfusion reaction
Subcategory 999.8 classifies other and unspecified transfusion reactions not classifiable to the 999.6 and 999.7 subcategories. Subcategory 999.8 excludes certain specified transfusion complications classifiable elsewhere, including: posttransfusion fever (780.66), hemochromatosis due to repeated transfusions (275.02), posttransfusion purpura (287.41), and transfusion-associated fluid overload (276.61).
Many hospitals and other facilities use pre-printed forms for transfusion reactions. If these forms do not contain the specific details that are now inherent in the ICD-9-CM diagnosis codes, the HIM manager should suggest that they be added. This form is an extremely important piece of documentation that can help ensure the appropriate classification of the various types of transfusion reactions. As always, if there is a question regarding the specific type of transfusion reaction, the physician should be contacted for clarification.
After review, take the quiz below to test your knowledge:
Questions
1. A patient with sickle cell anemia develops tachycardia, tachypnea and hypotension following blood transfusion. The transfusion was aborted. The patient was placed on IV saline, furosemide and low-dose dopamine to improve renal support and prevent shock due to acute hemolytic transfusion reaction. Donor blood was re-typed and crossed, resulting in identification of ABO incompatibility clerical error at the blood bank, resulting in mislabeling. The most appropriate diagnosis code(s) is/are:
a. 999.77, 282.60, E876.0
b. 999.62, 282.60, E876.0
c. 999.84, 282.69, E876.0
d. 999.62, 282.69, E876.0
2. A patient presents to the emergency department with epistaxis and purpura. She is 5 days post-transfusion and now presents with severe thrombocytopenia. Laboratory testing is positive for HPA-1a antibodies. The patient is admitted to the hospital and treated with intravenous immunoglobulin (IVIG) and corticosteroids. The most appropriate diagnosis code(s) is/are:
a. 287.41
b. 275.02
c. 276.61
d. 999.89, E879.8
3. A frail, elderly patient with atrial fibrillation controlled on Coumadin presents with fracture of the femur for open reduction, internal fixation (ORIF) repair. However, his INR was 2.9 on admission, so he received two units of fresh frozen plasma (FFP) to reverse anticoagulation. He then received four additional units over a 5-hour period for a total of six units FFP, approximately 1,200 ml. The patient then developed acute respiratory distress, hypertension, tachycardia, elevated central venous and pulmonary artery wedge pressure and jugular venous distension or S3 gallop on physical exam, consistent with transfusion-associated circulatory overload. He responded rapidly with supportive care and diuresis. The most appropriate diagnosis code(s) is/are:
a. 821.00, 276.69, 427.31, V58.61
b. 820.8, 276.62, 427.31, V58.61
c. 820.8, 276.61, 427.32, V58.61
d. 821.00, 276.61, 427.31, V58.61
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, facility solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix. The authors thank Beth Ford, RHIT, CCS, for her assistance with the clinical information found in this article.
Answers
1. b. The diagnosis was stated to be an acute hemolytic transfusion reaction due to an ABO incompatibility error. Code 999.62 is assigned, along with code 282.60 for the unspecified sickle cell disease (no crisis documented) and E876.0, that represents mismatched blood in transfusion.
2. a. Code 287.41 Posttransfusion purpura is the most appropriate code. There is no documentation of any of the other conditions in the choice list.
3. d. Because the patient was admitted for treatment of the femur fracture, code 821.00 is assigned as the principal diagnosis. Transfusion associated circulatory overload is assigned to code 276.61. Secondary codes are also assigned for the underlying atrial fibrillation (427.31) and the status V58.61 code to reflect the fact that the patient is on long-term (current) anticoagulant use.
