ICD-10 Coding for Acute Hepatitis(B16.9, B15.9)
Complete ICD-10-CM coding and documentation guide for Acute Hepatitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Acute Hepatitis
B15-B19Primary Range
Viral hepatitis
This range includes all types of viral hepatitis, both acute and chronic, with specific codes for different viral agents and conditions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| B16.9 | Acute hepatitis B without delta-agent and without hepatic coma | Use when acute hepatitis B is confirmed without delta-agent and hepatic coma. |
|
| B15.9 | Acute hepatitis A without hepatic coma | Use when acute hepatitis A is confirmed without hepatic coma. |
|
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 acute hepatitis B
Essential facts and insights about Acute Hepatitis
Primary ICD-10-CM Codes for acute hepatitis
Decision Criteria
clinical Criteria
- Positive IgM anti-HBc indicates acute infection.
Applicable To
- Acute hepatitis B
Excludes
- Chronic hepatitis B
Clinical Validation Requirements
- Positive HBsAg
- Positive IgM anti-HBc
- ALT >200 IU/L
Code-Specific Risks
- Misclassification as chronic hepatitis
Coding Notes
- Ensure documentation specifies acute status and absence of delta-agent.
B15.9 - Acute hepatitis A without hepatic coma
Use when acute hepatitis A is confirmed without hepatic coma.
Applicable To
- Acute hepatitis A
Excludes
- Chronic hepatitis A
Clinical Validation Requirements
- Positive anti-HAV IgM
- ALT >200 IU/L
Coding Notes
Ensure documentation specifies acute status and absence of hepatic coma.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Acute Hepatitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code B16.9.
Impact
Clinical: Leads to inappropriate treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Ensure serology results are documented., Query for missing information.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces accuracy of health records.
Mitigation Strategy
Query for specific serology results to identify the type of hepatitis.
Impact
Risk of audits due to unspecified hepatitis type.
Mitigation Strategy
Ensure complete serology documentation.
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 Acute Hepatitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Acute Hepatitis
Use these documentation templates to ensure complete and accurate documentation for Acute Hepatitis. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Acute Hepatitis
Specialty: Emergency MedicineRequired Elements
- Symptoms onset
- Jaundice presence
- ALT/AST levels
- Serology results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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