Q:  Question about fatty liver disease.  It’s my understanding that fatty liver disease is often the first stage in liver disease and can progress to cirrhosis.  If the provider documents fatty liver disease as well as cirrhosis, should you code both or is the cirrhosis enough?  The excludes notes don’t prevent coding them together.

A:  There can be cirrhosis and fatty liver conditions existing separately, possibly from the same etiology but possibly not, so we shouldn’t assume.  For example a patient may have NAFLD but have alcoholic cirrhosis.  In that case the choice to code them separately is pretty clear.  But what about NASH which is documented as having progressed to cirrhosis, which is a known outcome.  But it’s not a definite outcome and they are not mutually exclusive I’d recommend coding coding both, in the sense of coding essentially an etiology and a manifestation.  Taking a clue from the instructional note with NASH K75.81, it says to code the hepatic fibrosis from K74.0.  After all, cirrhosis is close cousins to hepatic fibrosis, so that supports the idea of also coding cirrhosis with NASH, whether it was the etiology or not.

Q:  How is acetaminophen overdose toxic to the liver and how does Mucomyst work as an antidote?

A:  Acetaminophen in normal doses is easily metabolized by the liver, but the pathway that does this has a limited capacity.  It’s called conjugation and many substances are eliminated this way.  The alternate pathway for acetaminophen results in certain metabolic pathway that generates a toxic called NAPQI that reacts with proteins, namely those in the liver.  This is what causes liver toxicity.  Normally, this too is detoxified by conjugation by a different pathway, but this is limited by the level of glutathione in the liver.  Mucomyst, chemical name acetylcysteine, replenishes the glutathione so the liver can keep detoxifying the NAPQI resulting from the acetaminophen overdose.

There are many different levels of acetaminophen overdose, and phases of treatment, so your poisoning code will have different episode of care characters as time progresses.  And the resulting liver condition may range from mild LFT elevation up to liver failure with coma, and this may evolve over time, so be precise with your coding of the conditions present at the current care encounter.

Q:   If a TIPS has a clot occluding it and a catheter-based thrombectomy is done, what is the correct PCS body part and root operation for the procedure?

A:   Just about anything done to a device that is not working correctly in some way is coded as a PCS Revision, which includes a TIPS stent.  And although the stent resides in the liver, don’t be tempted to code an Extirpation of liver or hepatic vein, for example.  Since the thrombosis is a problem with the stent graft, just go with the Revision of synthetic substitute in lower vein.  Interestingly, a TIPS is not an intraluminal device, because though it connects two lower veins, it is not properly inside either vein.  Also, though the thrombectomy does open up the lumen of the TIPS graft, avoid thinking of coding Dilation, because again, it is a device, so Revision is the right choice.





Ed has been in healthcare his entire career with 15 years as a clinician and 11 years in a variety of HIM coding related roles. After 4 years as a respiratory therapist and 11 years as an emergency medicine Physician Assistant, the fascination with reading, analyzing, and translating medical documentation overcame his desire to perform patient care. For a guy who with a habit for reading the Encyclopedia Brittanica, the Merck Manual, and medical records just for fun, HIM became a natural fit.

Documentation and coding audits are firmly in Ed’s skillset but educating coders is what really makes him tick. He is known for effectively integrating anatomy, physiology, pathophysiology, medicine, and detailed procedural descriptions into his coding education in all forms.

He is a BS graduate in Biology from Virginia Commonwealth University and Master of Health Sciences from Duke University. Obsessed with aviation, he has a pilot’s license, 1000 skydives, owned an ultralight for several years, and currently designs, builds, and flies radio controlled airplanes and drones. Ed lives in Virginia with his wife and two kids, and plays outside with them as much as possible.


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