Gastroenterology Coding Alert

Question: A patients medical record reads, Cirrhosis likely secondary to alcohol dependency complicated by varices with GI bleeding. The gastroenterologist was seeing this patient because of the cirrhosis, but which cirrhosis diagnosis code should be used? Do I use alcoholic cirrhosis (571.2) because alcohol is mentioned as a likely cause? Or do I use cirrhosis without mention of alcohol (571.5)?

Kentucky Subscriber

Answer: Depending on what (if any) procedures were performed during this encounter, you might be able to avoid the cirrhosis question altogether by reporting gastrointestinal bleeding as the diagnosis (578.9, hemorrhage of gastrointestinal tract, unspecified), says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

There is more specificity in reporting the esophageal varices, however, and specificity is usually considered to be more desirable in ICD-9 coding. The code for esophageal varices is 456.2 (esophageal varices in diseases classified elsewhere). However, a note in the description of this code in the ICD-9 manual states that you must code the underlying cause (either cirrhosis of the liver or portal hypertension) as the primary diagnosis, which forces you to choose between alcoholic and non-alcoholic cirrhosis, Stout explains.

Because the gastroenterologist is not sure this is alcoholic cirrhosis, it should not be coded as such, and you should use 571.5. Physicians cannot code for suspect, rule-out or probable diagnoses, Stout says.

This practice safeguards the patient as well. If it turns out that it is not alcoholic cirrhosis, you have falsely labeled that patient as alcohol-dependent with his or her insurance company, Stout notes.