Gastroenterology Coding Alert

Question: Our physician saw a 60-year-old male patient who presented with complaints of abdominal bloating along with fever, malaise, nausea, vomiting, and severe weight loss occurring over a month-long period. He complained of pain and tenderness in the abdominal area, swollen ankles, and difficulty breathing. His past medical history revealed alcohol abuse spanning many years, and the patient reported that he drank about 12 to 15 beers every evening. After performing a physical examination and several diagnostic tests, the physician diagnosed the patient with alcoholic cirrhosis of the liver with ascites. Which code applies?

Massachusetts Subscriber

Answer: 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. Again, 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.