Inpatient Facility Coding & Compliance Alert

Remember to look for additional complications in the documentation.

When ICD-10 goes into effect in October 2015, you’ll need to watch more details when reporting portal hypertension. Coexisting conditions or complications, along with any signs and symptoms, will all need to be considered when selecting the best diagnosis code. 

Under ICD-9, the diagnosis of portal hypertension can be reported with 572.3 (Portal hypertension). In most cases portal hypertension presents as a complication of liver cirrhosis (571.2, Alcoholic cirrhosis of liver), but there can be other causes, too. Also look for further complications such as portal hypertensive gastropathy and report it separately with 537.89 if it exists.

Under the ICD-10 set of codes, portal hypertension crosswalks to K76.6 (Portal hypertension). Report any associated complications such as portal hypertensive gastropathy with a separate code using K31.89. Also, remember to use an additional code for documented alcohol abuse and dependence (F10.-). The list of exclusions will comprise jaundice NOS (R17), hemochromatosis (E83.11-), Reye’s syndrome (G93.7), viral hepatitis (B15 – B19) and Wilson’s disease (E83.0).

Watch for Details in Documentation

Signs and symptoms of a patient with portal hypertension often will include fever, weakness, nausea, vomiting, abdominal pain, weight loss, anorexia, sudden bleeding, ascites, and signs of jaundice, muscle cramps, dark stools and changes to mental well being.

While examining the patient, the provider might note signs of anemia, jaundice, ascites, splenomegaly, dyspnea, tachypnea, hemorrhoids, parotid enlargement and arterial hypotension.

This can be followed by typical lab tests such as CBC, coagulation tests, BUN, creatinine, electrolyte levels and liver function tests or more detailed investigations may include ultrasonography, MRI or a CT scan to confirm the diagnosis.

Sometimes, the provider might perform measure of the hepatic venous pressure gradient in order to assess the progress of the condition and to help ascertain treatment response. He will also resort to an upper EGD procedure to check for the presence of esophageal varices and to enable therapeutic intervention.

Example: Your physician assesses a 64-year-old male patient for complaints of abdominal pain, vomiting and nausea that has been persistent for the past 15 days or so. The patient also complains of severe weight loss and anorexia that has been present for a couple of months now. The patient is HIV positive and has been on antiretroviral therapy for about four years. He has no history of alcohol intake or drugs. He says that he has had no abdominal complications until now.

On examination, the patient depicted signs of anemia, dyspnea, tachypnea and ascites. The provider ordered lab tests like CBC, coagulation time, LFT, BUN, creatinine, albumin, globulin and bilirubin levels. The LFT tests showed increased levels of AST (Aspartate transaminase); ALT (Alanine transaminase) and GGT (Gamma GlutamylTranspeptidase) while creatinine, albumin, globulin and bilirubin levels were all normal.

The patient’s abdominal CT scan showed the presence of ascites and portal vein thrombosis with no signs of any splenomegaly. An upper EGD revealed one Grade 2 and two Grade 1 esophageal varices but no signs of hemorrhage or bleeding from the varices.

Based on the above findings, the physician confirms a diagnosis of portal hypertension.

Code it: Submit the following codes for the above example: 

• Report the evaluation of the patient using 99223 (Initial hospital care, per day, for the evaluation and management of a patient…). 
• Report the EGD procedure done to control the bleeding with 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).
• Report the diagnosis with 572.3 when using ICD-9 codes or report K76.6 while using ICD-10 codes.

Note: Since the E/M service was done on the same date, there is a possibility of denial based on the assumption that all E/M services performed on the date of any procedure are included in the procedure fee.

In such a case, one should appeal the denial and append modifier -57 (Decision for surgery) to the E/M service for the evaluation a patient who, as a result of that evaluation, requires a procedure that will be performed the same day. This is the decision-making E/M.