Gastroenterology Coding Alert

Also: gain insight into documentation requirements.

While your gastroenterology practice is likely to see patients with liver conditions, you’re likely to be unclear on when and how to code them. Don’t worry. You’re not alone. Liver condition coding can be confusing because many problems associated with the liver have non-specific symptoms or exist with other conditions.

If you’re looking for some clarity when it comes to liver condition coding, this one’s for you.

Avoid Coding Liver Involvement Prematurely

The liver is a complex organ that performs many different functions, which can make it difficult for physicians to pinpoint the details of a liver condition. Just like with other uncertain diagnoses, even if the provider suspects liver disease or another liver ailment, be sure to code the signs and symptoms until an official diagnosis is made. As you already know, according to ICD-10-CM Official Guidelines, Section I.B.4, you need to code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.”

As far as practical application, the reality is that patients with liver conditions experience a range of symptoms, all of which could be indicative of numerous other conditions. This means the provider is going to document many different symptoms while trying to deduce a diagnosis. “While documentation may show tests and differential diagnoses that may end up being accurate, the coder cannot interpret the patient’s condition. It must be clearly stated by the treating provider(s),” explains Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education, Olympia Medical in Livonia, Michigan

Here are a few common symptoms you may encounter, as well as their corresponding ICD-10 codes:

• R63.0 (Anorexia)
• R63.4 (Abnormal weight loss)
• R53.83 (Other fatigue)
• R10.1- (Pain localized to upper abdomen)
• R11.2 (Nausea with vomiting, unspecified)

Sort Through the Documentation to Support Medical Necessity

If the gastroenterologist suspects the patient’s common symptoms have a less than common cause, that hunch isn’t going to be enough evidence for the payer. This is again where signs and symptoms play an important role. Reporting all the related symptoms and attaching the written report with the physician’s thought processes is the best way to justify medical necessity for any additional testing or imaging that can help find a definitive diagnosis.

Example: Your gastroenterologist assesses a 60-year-old male patient who arrives with complaints of abdominal tenderness along with low-grade fever, fatigue, nausea, and confusion. He also complains of persistent vomiting over several days. He provides a history of alcohol use over several years. During the physical examination, the physician documents peripheral edema, hepatosplenomegaly with signs of tenderness, abdominal dullness due to ascites, and notes tachycardia with tachypnea. They also note signs of muscle wasting and gynecomastia. These findings may code to the following:

• R60.9 (Edema, unspecified)
• R16.2 (Hepatomegaly with splenomegaly, not elsewhere classified)
• R18.8 (Other ascites)
• R00.0 (Tachycardia, unspecified)
• R06.82 (Tachypnea, not elsewhere classified)
• M62.5 (Muscle wasting and atrophy, not elsewhere classified)
• N62 (Hypertrophy of the breast)

Based on history and physical findings, your gastroenterologist suspects alcoholic hepatitis. They order diagnostic tests including CBC, liver function tests to determine 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. To support medical necessity, you will need to report the signs and symptoms that show the need for each test.

Documentation alert: If the documentation states only which tests the physician requests and a list of symptoms, the payer may request a more distinct thought process, including possible diagnoses and an explanation of why certain symptoms point to problems with liver function that would call for the tests ordered. “Tell a story with your documentation. Don’t rely on diagnosis documentation alone,” said to Kim Huey, MJ, CPC, CPCO, COC, CHC, CCS-P, PCS, president, KGG Coding and Reimbursement Consulting and Sandy Giangreco Brown, BS, RHIT, CHC, CCS, CCS-P, CPC, CPC-1, COBGC, COC, PCS, director of coding and revenue integrity at CLA in their presentation “Medical Necessity: Defining and Documenting to Support Billing.”

Check for Additional Coding Requirements Associated with Diagnosis

Let’s say the patient returns for results of the tests, the gastroenterologist officially diagnoses alcoholic hepatitis. Since your gastroenterologist mentions dullness over the abdomen due to ascites, you can report K70.11 (Alcoholic hepatitis with ascites).

You’re not in the clear yet, however. There is a Use additional note under K70 (Alcoholic liver disease) instructing you to account for alcohol use and dependence by coding to F10.- (Alcohol related disorders).

Understand Presenting Versus Chronic Conditions

Sometimes a patient has an underlying, chronic liver condition. Do you code that condition at every subsequent encounter?

According to ICD-10 guideline IV.I, “codes for chronic conditions should be used as often as the patient receives treatment and care for those conditions.” This can often seem like a gray area for many coders, especially if the provider doesn’t explicitly describe the two conditions in those ways.

Let’s say a liver cancer patient recently had an upper endoscopy because of the gastroenterologist’s suspicion of esophageal varices. The provider confirms that diagnoses and details that the varices are a direct result of the cancer. The patient’s most current problem is the varices. The provider has written specifically that this is a condition that is caused by the cancer. That means you need to code both. The provider is considering the cancer as significantly relevant to the care provided during the encounter.

Coding: On the first line of your claim, you would list I85.00 (Esophageal varices without bleeding) for the presenting problem, and then report the appropriate liver cancer code, such as C22.0 (Liver cell carcinoma).

Now, if the primary reason for the visit is unrelated to the cancer, do not code the cancer. For instance, the liver cancer patient could see their gastroenterologist for indigestion. While it’s possible the provider might consider this to be related to the cancer and treat it accordingly, they also might not. If the provider does, you need to code K30 (Functional dyspepsia) as well as C22.0. Otherwise, code only K30. If the relationship between the acute and chronic condition is unclear, query your provider.