ICD-10 Coding for Elevated Liver Function(R94.5, R74.01)
Complete ICD-10-CM coding and documentation guide for Elevated Liver Function. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Elevated Liver Function
R94.5Primary Range
Abnormal results of liver function studies
Used for unspecified abnormal liver function test results.
Elevated transaminase and lactic acid dehydrogenase levels
Used for isolated elevation of transaminases without a specified cause.
Toxic liver disease with various manifestations
Used for liver dysfunction due to drug or toxin exposure.
Fatty (change of) liver, not elsewhere classified
Used for nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH).
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R94.5 | Abnormal results of liver function studies | Use when liver function tests are abnormal but no specific cause is identified. |
|
| R74.01 | Elevated transaminase and lactic acid dehydrogenase levels | Use for isolated elevation of ALT/AST when no specific cause is documented. |
|
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 function tests
Essential facts and insights about Elevated Liver Function
Primary ICD-10-CM Codes for elevated liver function
Decision Criteria
clinical Criteria
- No specific etiology identified for abnormal liver function tests.
Applicable To
- Abnormal liver function test
Excludes
- Specific liver diseases (K70-K77)
Clinical Validation Requirements
- ≥2 abnormal liver function tests (e.g., ALT, AST, ALP, GGT)
Code-Specific Risks
- May lead to lower reimbursement if a more specific code is applicable.
Coding Notes
- Ensure documentation specifies the absence of a known cause for the elevation.
R74.01 - Elevated transaminase and lactic acid dehydrogenase levels
Use for isolated elevation of ALT/AST when no specific cause is documented.
Applicable To
- Elevated ALT/AST without specified cause
Excludes
- Toxic liver disease (K71.-)
Clinical Validation Requirements
- Isolated ALT/AST >3x ULN for >28 days
Coding Notes
Document any potential contributing factors such as medication use.
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 Elevated Liver Function to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R94.5.
Impact
Clinical: May lead to inappropriate management of the underlying condition., Regulatory: Increases risk of audit and compliance issues., Financial: Potential for reduced reimbursement due to unspecified coding.
Mitigation Strategy
Thoroughly review patient history and medication use, Document any suspected causes in the medical record
Impact
Reimbursement: May result in lower reimbursement due to unspecified coding., Compliance: Increases risk of audit for lack of specificity., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use a more specific code such as K71.2 for toxic liver disease.
Impact
Increased scrutiny on the use of unspecified codes like R94.5.
Mitigation Strategy
Ensure documentation supports the use of specific codes whenever possible.
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 Elevated Liver Function, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated Liver Function
Use these documentation templates to ensure complete and accurate documentation for Elevated Liver Function. These templates include all required elements for proper coding and billing.
Elevated Liver Function Tests in Primary Care
Specialty: Internal MedicineRequired Elements
- Patient history including alcohol and medication use
- Physical examination findings
- Laboratory results
- Imaging studies if performed
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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