ICD-10 Coding for Abnormal Liver Enzyme(R74.01, R94.5)
Complete ICD-10-CM coding and documentation guide for Abnormal Liver Enzyme. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Liver Enzyme
R74.0-R74.8Primary Range
Abnormal serum enzyme levels
This range includes codes for specific abnormal liver enzyme levels, such as elevated transaminases and alkaline phosphatase.
Abnormal results of liver function studies
Used for abnormal liver function tests when specific enzymes are not identified.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R74.01 | Elevated liver transaminases | Use when ALT or AST levels are elevated without a specific diagnosis. |
|
| R94.5 | Abnormal liver function studies | Use when multiple liver function tests are abnormal but specific enzymes are not identified. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for elevated liver enzymes
Essential facts and insights about Abnormal Liver Enzyme
Primary ICD-10-CM Codes for abnormal liver enzyme
Decision Criteria
clinical Criteria
- ALT or AST levels exceed normal reference range.
Applicable To
- Elevated ALT
- Elevated AST
Excludes
- Specific liver diseases (K70-K77)
Clinical Validation Requirements
- ALT >40 U/L
- AST >40 U/L
Code-Specific Risks
- Misuse when a specific liver disease is diagnosed.
Coding Notes
- Ensure documentation explicitly states elevated transaminases.
R94.5 - Abnormal liver function studies
Use when multiple liver function tests are abnormal but specific enzymes are not identified.
Applicable To
- Abnormal LFT panel
Excludes
- Specific enzyme elevations (R74.01, R74.8)
Clinical Validation Requirements
- Multiple abnormal liver function tests without specific enzyme identification.
Coding Notes
Document all abnormal components of the LFT panel.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Right upper quadrant pain
R10.11Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Liver Enzyme to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R74.01.
Impact
Clinical: Leads to vague clinical data., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure documentation lists all abnormal LFT components., Use specific codes when possible.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R74.01 for transaminase-specific elevations.
Impact
Using R94.5 for specific enzyme elevations.
Mitigation Strategy
Educate coders on the distinction between R94.5 and enzyme-specific codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Liver Enzyme, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Liver Enzyme
Use these documentation templates to ensure complete and accurate documentation for Abnormal Liver Enzyme. These templates include all required elements for proper coding and billing.
Elevated ALT with no diagnosis
Specialty: GastroenterologyRequired Elements
- Patient symptoms
- Lab results with reference ranges
- Provider interpretation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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