Gastroenterology Coding Alert

Question: A patient’s 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 I use? Should I use alcoholic cirrhosis (571.2) because the gastroenterologist mentioned this as a likely cause? Or should 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).

However, you should take into account more specificity in reporting the esophageal varices because ICD-9 rules require the most specific code. The code for esophageal varices is 456.20 (Esophageal varices in diseases classified elsewhere; with bleeding). 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.

Important: Because the gastroenterologist is not sure this is alcoholic cirrhosis, you should not code it as such, and you should use 571.5 (physicians cannot code for suspect, rule-out or probable diagnoses). 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.