Gastroenterology Coding Alert

Can you find the right diagnosis code for these liver conditions?

From cirrhosis to hepatitis and beyond, your gastroenterology practice is likely to see patients with liver conditions, and coding these can sometimes require extensive sleuthing. That’s because your coding options for these diagnoses change depending on the condition’s cause —sometimes they may be due to alcohol intake, but not always.

Check these three scenarios to determine whether you can report these conditions correctly.

Case 1: Alcoholic Cirrhosis

Scenario: Your gastroenterologist assesses a 52-year-old male patient who arrives with complaints of abdominal bloating along with fever, malaise, nausea, vomiting, and severe weight loss occurring over a month-long period. He complains of pain and tenderness in the abdominal area, swollen ankles, and difficulty breathing. His past medical history reveals alcohol abuse spanning many years, and the patient reports that he currently drinks about 12 to 15 beers every evening.

Your gastroenterologist assesses the patient and performs a physical examination. During the examination, the doctor notes spider nevi, peripheral edema, hepatosplenomegaly with signs of tenderness, abdominal dullness due to ascites, and signs of jaundice. The physician also notes some signs of muscle wasting and gynecomastia, along with clubbing of nails.

Based on the patient’s history and the physical findings, your gastroenterologist suspects alcoholic cirrhosis of the liver. The doctor orders diagnostic tests such as a complete blood count and liver function tests to measure albumin and bilirubin levels, along with liver enzymes such as AST and ALT levels. The physician also orders prothrombin time and globulin level tests, as well as an ultrasound to help confirm the diagnosis of alcoholic cirrhosis. Plus, the GI physician performs an upper EGD, confirming the presence of esophageal varices, and treats it with a sclerosing agent.

Upon review of the history, signs and symptoms, and results of diagnostic tests, your gastroenterologist arrives at a diagnosis of alcoholic cirrhosis of the liver with ascites.

Coding Solution: Since your gastroenterologist mentions dullness over the abdomen due to ascites with the cirrhosis, report K70.31 (Alcoholic cirrhosis of liver with ascites) for this condition. If the physician needs to report a diagnosis code before coming to the final confirmation of this condition, you’ll instead report the signs and symptoms that prompted any services or testing.

Case 2: Portal Hypertension

Scenario 2: Your gastroenterologist sees a 64-year-old male patient for complaints of abdominal pain, vomiting, and nausea that have been persistent for the past two weeks. The patient also complains of severe weight loss for a couple of months now. The patient is HIV positive and has been on antiretroviral therapy for about four years. He has no history of alcohol intake or drugs. He says that he has had no abdominal complications until now.

Upon examination, your clinician notes signs of anemia, dyspnea, tachypnea, and ascites. Your gastroenterologist asks for lab tests like CBC, coagulation time, LFT, BUN, creatinine, albumin, globulin and bilirubin levels. The LFT tests show increased levels of AST (Aspartate transaminase); ALT (Alanine transaminase) and GGT (Gamma Glutamyl Transpeptidase) while creatinine, albumin, globulin, and bilirubin levels are all normal.

The patient’s abdominal CT scan shows the presence of ascites and portal vein thrombosis. There are no signs of any splenomegaly. Your gastroenterologist performs an upper EGD that reveals one Grade 2 and two Grade 1 esophageal varices but no signs of hemorrhage or bleeding from the varices.

Based on history, signs and symptoms, physical examination, and results of lab tests and diagnostic studies, your clinician arrives at a diagnosis of portal hypertension.

Coding Solution: You should report the diagnosis with K76.6 (Portal hypertension). You will also need to report any complications such as portal hypertensive gastropathy and esophageal varices without bleeding with a separate code.

Reminder: Although in this case alcohol was not the cause of portal hypertension, in cases where alcohol is involved, you’ll have to also use an additional code to help identify alcohol abuse and dependence (F10.-). The choice of which code to select will depend on whether the alcohol use disorder is still active or in remission, advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

Case 3: Alcohol-Related Hepatitis

Scenario 3: Your gastroenterologist assesses a 55-year-old male patient who arrives with complaints of abdominal tenderness along with low-grade fever, malaise, nausea, and confusion. He also complains of persistent vomiting over several days. He provides a history of alcohol use over several years.

Your gastroenterologist assesses the patient and performs a physical examination. During the examination, the physician notes peripheral edema, hepatosplenomegaly with signs of tenderness, abdominal dullness due to ascites, and notes tachycardia along with tachypnea. They don’t find signs of spider angiomata, although the physician does see some signs of muscle wasting and gynecomastia.

Based on history and physical findings, your gastroenterologist arrives at a possible diagnosis of alcoholic hepatitis. They order diagnostic tests including CBC, liver function tests to measure out albumin and bilirubin levels along with liver enzymes such as AST and ALT levels. They also order some screening tests such as HBsAg, Hepatitis C antibody, and ferritin levels to rule out other causes for the signs and symptoms of hepatitis. They also order an abdominal sonogram to help assess the liver contours and density and to check for signs of cirrhosis including ascites and portal hypertension. Upon review of the history, signs and symptoms, and results of diagnostic tests, your gastroenterologist arrives at a diagnosis of alcoholic hepatitis.

Coding Solution: Since your gastroenterologist mentions dullness over the abdomen due to ascites, you can report K70.11 (Alcoholic hepatitis with ascites).