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December 21, 2009

Coding for Liver Disease
For The Record
Vol. 21 No. 24 P. 28

Alcoholic fatty liver (571.0) is the most common liver problem experienced by people who are alcohol dependent. The liver will appear enlarged, firm, and yellowish as the organ’s cells become swollen with fat from the body’s fat cells and the person’s daily diet. Alcoholic fatty liver can be reversed if a person stops drinking.

Alcoholic hepatitis (571.1) is liver inflammation due to alcohol. The liver also appears enlarged, firm, and yellowish, and the damage may be reversible with alcohol cessation. With more severe cases of alcoholic hepatitis, liver cells may die. This is the middle step between fatty liver and alcoholic cirrhosis.

Alcoholic cirrhosis (571.2) is an end-stage disease, with cirrhosis referring to the replacement of normal liver tissue with scar tissue. If drinking does not cease, more liver cells die. With continued scarring, the liver shrinks, becomes firm, and can no longer function. Cirrhosis is permanent, even if a person stops drinking.

Alcoholic liver disease (571.3) is a nonspecific term, so it is necessary to have the physician clarify the stage of disease.

There are often no symptoms of alcoholic fatty liver disease until the person seeks treatment for another medical issue. Symptoms of alcoholic hepatitis can range from mild to critical and may include fever, loss of appetite, abdominal distress, nausea and vomiting, weight loss, diarrhea, or jaundice.

Alcoholic cirrhosis takes longer to develop with continued excessive drinking and has a slow onset of symptoms. The liver shrinks, feels firm, and becomes scarred and nodular. Scarring around the veins in the liver causes collateral circulation similar to varicose veins in the legs. This can lead to large swollen veins in the throat, rectum, abdomen, and chest. Common symptoms of alcoholic cirrhosis include weakness and fatigue; loss of muscle mass; muscle cramps; leg swelling; ascites; loss of body hair, a lowered sex drive, and shrinkage of the testes in men; increased facial hair, a deep voice, and menstrual problems in women; seizures; and gastrointestinal bleeding/esophageal varices.

To diagnose alcoholic liver disease, the physician may order liver function tests and blood tests. The physician will look for elevated creatine phosphokinase (CPK), serum glutamic-oxaloacetic transaminase (SGOT), lactate dehydrogenase (LDH), and alanine transaminase (ALT)/aspartate transaminase (AST) to prothrombin time (PT)/international normalized ratio (INR) to substantiate the diagnosis. In addition, the physician may order a liver biopsy for definitive diagnosis and also review ultrasound and CT scans to rule out other diseases.

The immediate goal is discontinuation of alcohol use, and the treatment objective is to provide a high-carbohydrate, high-calorie diet to reduce protein breakdown in the body. Supplements such as B1 vitamins and folic acid may be needed due to poor dietary intake. It also may be necessary for the patient to receive counseling or enter an alcohol rehabilitation program. If there are complications such as malnutrition, gastrointestinal bleeding, or portal hypertension, these conditions will also have to be managed. If cirrhosis develops, then a liver transplant may be necessary.

Nonalcoholic Fatty Liver Disease
Nonalcoholic fatty liver disease (NAFLD, 571.8) refers to a wide spectrum of liver disease ranging from simple fatty liver (steatosis) to nonalcoholic steatohepatitis (NASH, 571.8) and finally cirrhosis. It has a similar progression as alcoholic liver disease but occurs in those who consume little or no alcohol. It is a common, often “silent” liver disease. The major features are fatty deposits in the liver, inflammation, and damage. Most people with NAFLD are unaware that they have a liver problem.

The prevalence of NAFLD and NASH are increasing and are presumably more likely to occur in people who are obese or have diabetes. NASH is typically a disease experienced by middle-aged women who are overweight with predominant abdominal fat distribution. However, there are also increasing reports of NASH related to male and pediatric obesity. Currently, NAFLD accounts for a sizeable percentage of all liver transplants and is expected to become the leading indication for both adult and pediatric transplants within the next 10 years.

Coding and sequencing for liver disease are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.