General Surgery Coding Alert
Guide Your Liver Condition Coding to Clean Claims
Focus on presenting Dx. When your surgeon treats a patient with a liver condition, knowing what and how to document the diagnosis to establish medical necessity can be a challenge. From cirrhosis to hepatitis to cancer, correct coding may — or may not — rely on documenting the condition’s underlying cause, such as alcohol intake or distant metastasis. If you’re looking for some clarity when it comes to liver condition coding, this one’s for you. Avoid Coding Liver Involvement Prematurely Patients with liver conditions experience a range of symptoms, all of which could indicate numerous other conditions. You can expect your surgeon to document many symptoms while trying to reach a final diagnosis. Here are a few common symptoms you may encounter, as well as their corresponding ICD-10-CM codes: If your surgeon orders tests or perhaps performs a liver biopsy, such as 47000 (Biopsy of liver, needle; percutaneous) or 47100 (Biopsy of liver, wedge), you shouldn’t report a “suspected” or “rule out” condition before the final diagnosis is available. “While documentation may show tests and differential diagnoses that may end up being accurate, the coder cannot interpret the patient’s condition. It must be clearly stated by the treating provider(s),” explains Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education, Olympia Medical in Livonia, Michigan. Do this: Until the final diagnosis is in, you should report just the documented signs and symptoms that represent the reason for further testing. That’s the gold standard of the ICD-10-CM Official Guidelines, Section I.B.4, which instructs you to code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.” Sort Through the Documentation to Support Medical Necessity Without a final diagnosis, you’ll need to search the surgeon’s notes for indicators of medical necessity. Hint: Reporting all the related symptoms and attaching the written report with the physician’s thought processes is the best way to justify medical necessity for any additional testing or imaging that can help find a definitive diagnosis. Example: Your surgeon assesses a 60-year-old male patient, who arrives with complaints of abdominal tenderness along with low-grade fever, fatigue, nausea, and confusion. He also complains of persistent vomiting over several days. He provides a history of alcohol use over several years. During the physical examination, the physician documents peripheral edema, hepatosplenomegaly with signs of tenderness, abdominal dullness due to ascites, and notes tachycardia with tachypnea. The surgeon also notes signs of muscle wasting and gynecomastia. Use the following codes to report those findings: Based on history and physical findings, your surgeon states, “suspicion of alcoholic hepatitis” and orders diagnostic tests including complete blood count (CBC) and liver function tests to determine albumin and bilirubin levels along with liver enzymes such as aspartate aminotransferase (AST) and alanine transaminase (ALT) levels. The surgeon also orders tests such as hepatitis B antigen (HBsAg), hepatitis C antibody (anti-HCV), and ferritin levels to rule out other causes for the signs and symptoms of hepatitis. Finally, the surgeon orders an abdominal sonogram to help assess the liver contours and density and to check for signs of cirrhosis, including ascites and portal hypertension. To support medical necessity, you will need to report the signs and symptoms that show the need for each test. Documentation alert: If the documentation states only which tests the physician requests and a list of symptoms, the payer may request a more distinct thought process, including possible diagnoses and an explanation of why certain symptoms point to problems with liver function that would call for the tests ordered. That’s why you should not rely on a list of diagnosis codes alone, but you should “tell a story with your documentation,” advises Kim Huey, MJ, CPC, CPCO, COC, CHC, CCS-P, PCS, president, KGG Coding and Reimbursement Consulting. Check for Additional Coding Requirements Associated with Diagnosis Continuing the previous example, the surgeon reviews the test results. Based on an AST:ALT ratio of 1.3, the surgeon concludes that the patient has liver cirrhosis, consistent with the symptoms. The positive HBsAg test indicates that the patient has an active hepatitis B infection. The symptomatic dullness over the abdomen plus sonogram findings indicate ascites. Do this: Assign a final diagnosis of K70.11 (Alcoholic hepatitis with ascites). But that’s not all. There is a Use additional note under K70 (Alcoholic liver disease) instructing you to account for alcohol use and dependence by coding to F10.- (Alcohol related disorders). Finally, you should report the hepatitis B diagnosis as B16.9 (Acute hepatitis B without delta-agent and without hepatic coma). Understand Presenting Versus Chronic Conditions Sometimes a patient has an underlying, chronic liver condition. Do you code that condition at every subsequent encounter? According to ICD-10-CM Guideline IV.I, “codes for chronic conditions should be used as often as the patient receives treatment and care for those conditions.” This can often seem like a gray area for many coders, especially if the provider doesn’t explicitly describe the two conditions in those ways. Let’s say a liver cancer patient recently had an upper endoscopy because of the surgeon’s suspicion of esophageal varices. The provider confirms that diagnoses and details that the varices are a direct result of the cancer. The patient’s most current problem is the varices. The physician has written specifically that this is a condition that is caused by the cancer. That means you need to code both. The clinician considers the cancer as significantly relevant to the care provided during the encounter. Coding: On the first line of your claim, you would list I85.00 (Esophageal varices without bleeding) for the presenting problem, and then report the appropriate liver cancer code, such as C22.0 (Liver cell carcinoma). Caveat: If the primary reason for the visit is unrelated to the cancer, do not code the cancer. For instance, if the patient sees the surgeon for ongoing indigestion, but the provider doesn’t indicate that the condition is related to the cancer, you should report K30 (Functional dyspepsia) without adding C22.0. Get the Cancer Coding Right ICD-10-CM provides multiple specific codes for primary liver cancer, such as the following: To report one of these codes, you’ll need a final diagnostic statement from a pathology report based on a procedure such as a liver biopsy. Metastatic is different: If the cancer in the liver has spread from another organ, you should not report a C22.- code. For instance, a patient has colon cancer and is reporting to your surgeon for a biopsy based on a spot found on the liver during imaging. The pathology report indicates that the spot on the liver is colon cancer that has metastasized to the liver, not primary liver cancer. In this case, you should not code the colon cancer (C18.9, Malignant neoplasm of colon, unspecified) as the primary diagnosis for the biopsy encounter. Nor should you code C22.8, because the biopsy findings indicate that the cancer in the liver is not the primary cancer. Do this: Based on the biopsy findings, the final diagnosis for the procedure is C78.7 (Secondary malignant neoplasm of liver and intrahepatic bile duct), which is the principal diagnosis for this encounter. Hot tip: For metastatic cancers, always closely scrutinize your provider’s documentation. “If your provider notes the cancer is metastatic to, that means the cancer is secondary. If the note reads metastatic from, that means the cancer is primary,” according to Jill Young, CEMC, CPC, CEDC, CIMC, of Young Medical Consulting LLC in East Lansing, Michigan.
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