Coagulation defects, also known as bleeding disorders and blood clotting disorders, are problems with the blood’s ability to form clots. The defects can involve the blood vessels and the cells and the proteins in the blood. Coagulation disorders refer to conditions that affect how the body controls blood clotting. Hemophilia, Von Willebrand disease, clotting factor deficiencies, hypercoagulable states (primary and secondary), and deep venous thrombosis are examples of coagulation disorders.

Coding tips:
Some coagulation disorders are genetic, and some patients acquire them during their lifetime from certain medications or conditions. Failure to take into consideration whether a patient’s coagulopathy results from medication therapy or from a systemic issue can result in misrepresentation of a person’s clinical complexity. If a patient’s chronic conditions are managed and treated with anticoagulants, clinical decision-making on secondary hypercoagulable state should be documented. When secondary hypercoagulable state is not documented, assign code Z79.01, long-term use (current) of an anticoagulant, to identify the patient’s anticoagulant management.

Documentation considerations:

• Identify if primary or secondary condition is due to another underlying condition.
• Document the underlying etiology or cause if known.
• If bleeding complication due to an antithrombotic or anticoagulant, documentation must link the bleeding to the use of the medication.
• Distinguish coagulation disorder from therapeutic treatment with antithrombotic or anticoagulant.
• Coagulation disorders listed in the past medical history or active problem list alone will not support adequate documentation.