Monthly CDI Scenario Discussion – March 2020

Topic: Pancytopenia

Scenario: A 51 year old female presents with nausea, vomiting, and weakness

History & Physical:

  • HPI: 51 year old female recently diagnosed with leukemia presents with nausea, vomiting, poor appetite, and weakness. Last chemotherapy treatment was one week prior to presentation.
  • PMH: Osteoarthritis, diabetes mellitus type 2, HTN, obesity (BMI 35), no history of smoking or alcohol use
    • Family History: mother died of leukemia, paternal grandmother died of breast cancer, and father died of lung cancer
  • Home Medications: HCTZ, Metformin, Ibuprofen, and Zofran prn
  • Labs: K 4, WBC 1.8 (absolute neutrophils .8 k/uL), Hgb 6.5, HCT 19, Platelets 45, Na 145, glucose 225
  • X-Ray: CXR- small nodule in left lower lobe- concerning for lung cancer
  • Consult: Oncologist notes pancytopenia. Plan to start Neupogen after chemo treatments in the future
  • Treatment: Continue home medications, 2 units PRBCs, dietary consult
  • Discharge Diagnoses: Leukemia, pancytopenia, dehydration, diabetes mellitus type II with hyperglycemia, HTN-controlled, obesity, osteoarthritis
  • Discharge Medications/Instructions: Iron supplement, continue home medication regime, follow up with Oncology for chemotherapy and possible biopsy of lung nodule

Question: Are there query opportunities based on the scenario stated above?

Discussion: Pancytopenia is defined as suppression of all three bone marrow cell-lines resulting in simultaneous neutropenia, thrombocytopenia, and anemia.

  • Neutropenia: Absolute neutrophils <1.5 k/uL
  • Thrombocytopenia: Platelets <100 k/uL (Coding Clinic, 4th Qtr 2014, p 22)
  • Anemia: Hgb <13.0 gm/dL (men), <12.0 (women), and <11.0 (pregnancy)

Pancytopenia treatment is usually directed at the cause and/or correction of one or more of the three suppressed cell lines. Anemia and thrombocytopenia can be treated with transfusion. Epogen and Procrit can be given for anemia. Neupogen is commonly used for severe neutropenia to stimulate bone marrow production.

UASI Recommends:

  • Query for cause of pancytopenia
  • Query for type of leukemia

Documentation without Clarification:

  • Working Principal Diagnosis: C9590 Leukemia, unspecified, not having achieved remission
  • Working Secondary Diagnoses: E1165 type 2 diabetes mellitus with hyperglycemia, E669 obesity, unspecified, Z6835 DMI 35.0-35.9, adult, D61818 other pancytopenia, E860 dehydration, M1990 unspecified osteoarthritis, unspecified site, I10 essential hypertension
  • Working Procedure: 30233N1-transfusion of non-autologous red blood cells into peripheral vein, percutaneous approach
  • Working MS-DRG: 841 lymphoma and non-acute leukemia with CC
  • RW: 1.6117, GMLOS: 4.1, SOI/ROM: 2/2

Documentation with Clarification:

  • Working Principal Diagnosis: C9200 acute myeloblastic leukemia, not having achieved remission
  • Working Secondary Diagnoses: E1165 type 2 diabetes mellitus with hyperglycemia, E669 obesity, unspecified, Z6835 BMI 35.0-35.9, adult, E860 dehydration, M1990 unspecified osteoarthritis, unspecified site, D61810antineoplastic chemotherapy induced pancytopenia, I10 essential hypertension
  • Working Procedure: 30233N1-transfusion of non-autologous red blood cells into peripheral vein, percutaneous approach
  • Working MS DRG: 834 acute leukemia w/o major OR procedure with MCC
  • RW: 5.8425, GMLOS: 10.1, SOI/ROM: 2/2

CDI Educational Tips:

Review the chart closely for etiology of pancytopenia.

  • Look for any medications (chemo), radiation, chemical exposures, recent infections, or any immunologic disorders
  • Recent Infections: Tuberculosis, Epstein-Barr, Cytomegalovirus
  • Many patients are asymptomatic until the anemia becomes a concern. They may present with malaise, vertigo, weakness, or palpitations.
  • Tests and labs may consist of CBC with peripheral smear, bone marrow biopsy, type and screen for PRBC, reticulocyte count

This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.

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