ICD-10 Coding for Steatohepatitis(K75.81, K76.0)
Complete ICD-10-CM coding and documentation guide for Steatohepatitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Steatohepatitis
K70-K77Primary Range
Diseases of liver
This range includes codes for liver diseases, including steatohepatitis and related conditions.
Obesity
Obesity is a common comorbidity with steatohepatitis and affects coding and reimbursement.
Type 2 diabetes mellitus
Type 2 diabetes is often associated with steatohepatitis and impacts coding.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K75.81 | Nonalcoholic steatohepatitis (NASH) | Use when there is documented inflammation and liver injury consistent with NASH. |
|
| K76.0 | Fatty (change of) liver, not elsewhere classified | Use when there is fatty liver without evidence of inflammation. |
|
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 steatohepatitis
Essential facts and insights about Steatohepatitis
Primary ICD-10-CM Codes for steatohepatitis
Decision Criteria
clinical Criteria
- Presence of lobular inflammation and ballooning degeneration on biopsy
coding Criteria
- Documented fibrosis stage
Applicable To
- NASH with inflammation
- NASH with fibrosis
Clinical Validation Requirements
- Biopsy showing steatosis, lobular inflammation, and ballooning degeneration
- FibroScan CAP score ≥275 dB/m
Code-Specific Risks
- Confusion with NAFLD without inflammation
- Inadequate documentation of fibrosis stage
Coding Notes
- Ensure documentation specifies inflammation and any fibrosis stage.
K76.0 - Fatty (change of) liver, not elsewhere classified
Use when there is fatty liver without evidence of inflammation.
Applicable To
- NAFLD without inflammation
Excludes
- NASH (K75.81)
Clinical Validation Requirements
- Imaging showing macrovesicular steatosis without inflammation
Coding Notes
Ensure no documentation of inflammation is present.
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 Steatohepatitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K75.81.
Impact
Clinical: Leads to misdiagnosis and treatment errors., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Use specific terms like 'steatohepatitis with ballooning degeneration'., Ensure biopsy results are detailed.
Impact
Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: May result in audit issues due to inaccurate coding., Data Quality: Affects clinical data accuracy and patient records.
Mitigation Strategy
Ensure documentation specifies presence or absence of inflammation.
Impact
Lack of specific fibrosis staging can lead to audit flags.
Mitigation Strategy
Ensure all biopsy reports include fibrosis stage.
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 Steatohepatitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Steatohepatitis
Use these documentation templates to ensure complete and accurate documentation for Steatohepatitis. These templates include all required elements for proper coding and billing.
NASH with fibrosis and obesity
Specialty: GastroenterologyRequired Elements
- Biopsy results
- Fibrosis stage
- BMI documentation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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