Documentation Tip of the Week: Cirrhosis

Posted on Wed, Jun 10, 2015
Documentation Tip of the Week: Cirrhosis

Documentation tips for clinicians. As a reminder, the implementation of ICD-10 coding begins Oct.1, 2015. ICD-10 replaces ICD-9 and is required for every patient who is covered by the Health Insurance Portability Accountability Act (HIPAA).

Don’t assume that cirrhosis is due to alcoholism unless specified.
ALWAYS document the underlying etiology of cirrhosis:

  • Hepatitis C Virus (HCV)
  • Alcoholic Liver Disease (ALD)
  • Cryptogenic (NASH)
  • Chronic hepatitis: viral, autoimmune

ALWAYS document associated conditions when present:
  • Esophageal varices
  • Hepatic encephalopathy*
  • WITH or WITHOUT ascites (critical for ICD-10)
  • Portal vein thrombosis  
  • Jaundice

*Remember - altered mental status or confusion does not mean encephalopathy. Be sure to document “hepatic encephalopathy” (MCC) and not just the signs/symptoms

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and he completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at 

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