Gastroenterology Coding Alert

Question: My gastroenterologist sees a patient for a "cirrhosis likely secondary to alcohol dependency complicated by varices with GI bleeding," according to medical records. What cirrhosis diagnosis code should I use?

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Answer: Interestingly, none between alcoholic cirrhosis (571.2) and 571.5 (Cirrhosis of liver without alcohol) could describe the condition more appropriately. Depending on what (if any) procedures the physician performed during this encounter, you should report it with gastrointestinal bleeding as the diagnosis (578.9, Hemorrhage of gastrointestinal tract, unspecified).

In the name of specificity, you should consider 456.20 (Esophageal varices in diseases classified elsewhere; with bleeding) as another option. 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.

Reminder: Do not code for suspect, rule-out or probable diagnoses. In this case, the gastroenterologist is not sure this is alcoholic cirrhosis, thus you should not code it as such. 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 insurance company.