ICD-10 Coding for Autoimmune Hepatitis(K75.4)
Complete ICD-10-CM coding and documentation guide for Autoimmune Hepatitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Autoimmune Hepatitis
Key Information: ICD-10 code for autoimmune hepatitis
Essential facts and insights about Autoimmune Hepatitis
Primary ICD-10-CM Code for autoimmune hepatitis
Decision Criteria
clinical Criteria
- Presence of specific autoantibodies and elevated IgG levels.
documentation Criteria
- Detailed biopsy report confirming interface hepatitis.
Applicable To
- Chronic active hepatitis with autoantibodies
Clinical Validation Requirements
- Presence of autoantibodies (ANA, SMA, anti-LKM1)
- Elevated IgG levels (>1.5x ULN)
- Liver biopsy showing interface hepatitis
Code-Specific Risks
- Misclassification with other types of hepatitis
- Incorrect sequencing with complications
Coding Notes
- Ensure all diagnostic criteria are met before coding K75.4.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Autoimmune Hepatitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K75.4.
Impact
Clinical: Misdiagnosis or delayed treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific terminology for hepatitis type., Ensure all diagnostic criteria are documented.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Use K75.4 when all diagnostic criteria for AIH are met.
Impact
Incomplete documentation of autoantibody titers can lead to audit issues.
Mitigation Strategy
Ensure all serological tests are documented with specific titers.
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 Autoimmune Hepatitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Autoimmune Hepatitis
Use these documentation templates to ensure complete and accurate documentation for Autoimmune Hepatitis. These templates include all required elements for proper coding and billing.
Initial diagnosis of autoimmune hepatitis
Specialty: GastroenterologyRequired Elements
- Autoantibody titers
- IgG levels
- Liver biopsy results
- Exclusion of viral hepatitis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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