ICD-10 Coding for Transaminitis(R74.01, K76.0)
Complete ICD-10-CM coding and documentation guide for Transaminitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Transaminitis
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 | Elevation of levels of liver transaminase levels | Use when ALT/AST levels are elevated without a confirmed underlying cause. |
|
| K76.0 | Fatty (change of) liver, not elsewhere classified | Use when NAFLD is confirmed as the cause of transaminitis. |
|
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 transaminitis
Essential facts and insights about Transaminitis
Primary ICD-10-CM Codes for transaminitis
Decision Criteria
clinical Criteria
- ALT/AST levels elevated without known cause.
coding Criteria
- Do not use as principal if underlying cause is identified.
Clinical Validation Requirements
- ALT >40 U/L for men, >35 U/L for women
- No identified cause after initial workup
Code-Specific Risks
- Using as principal diagnosis when an underlying cause is known.
Coding Notes
- Ensure documentation includes specific ALT/AST values and absence of known causes.
K76.0 - Fatty (change of) liver, not elsewhere classified
Use when NAFLD is confirmed as the cause of transaminitis.
Applicable To
- Non-alcoholic fatty liver disease (NAFLD)
Excludes
- Alcoholic liver disease (K70.-)
Clinical Validation Requirements
- Hepatic steatosis on imaging
- Presence of metabolic syndrome
Coding Notes
Ensure documentation specifies NAFLD diagnosis with supporting imaging.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fatty liver
K76.0Differential 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 Transaminitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R74.01.
Impact
Clinical: Inadequate clinical picture, Regulatory: Potential for coding errors, Financial: Risk of claim denials
Mitigation Strategy
Always include specific enzyme values, Document exclusion of common causes
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Identify and code the underlying cause as the principal diagnosis.
Impact
Using R74.01 as principal when an underlying cause is identified.
Mitigation Strategy
Ensure thorough documentation of clinical workup and identified causes.
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 Transaminitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Transaminitis
Use these documentation templates to ensure complete and accurate documentation for Transaminitis. These templates include all required elements for proper coding and billing.
Patient with unexplained elevated liver enzymes
Specialty: GastroenterologyRequired Elements
- ALT/AST values
- Imaging results
- Exclusion of common causes
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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