We’ve launched our “Village Advisor Program” where members of our CDI and Coding Village online community can give their own webinar and get paid.

The first will be by Laura Samson on Risk Adjustment. The 2nd will be by Penny Jenfferson on Elixhauser.

That’s not all.

7 days before the 1st presentation (TBD) we’ll have another exciting announcement. Stay tuned through my social media channels!

(Thanks to Dr. James Kennedy, who co-wrote this newsletter with me, and to hepatologist Dr. Steven Young for reviewing this newsletter)

One of the first questions I received as a new CDI physician advisor was, “Should I query for chronic hepatic failure?”

“Um…yes?…I think?” I thought to myself while being self-conscious about why that wasn’t an easy answer.

It wasn’t an easy answer because many physicians do not use the term “chronic hepatic failure.” Admittedly, we prefer to instead emphasize the consequences (hepatic encephalopathy, ascites, etc.) without mentioning the liver failure. This would be like documenting orthopnea, dyspnea on exertion, JVD, etc. without stating the patient has heart failure.

Therefore, physicians, pay attention. I’m going to get a bit deep into the ICD-10-CM coding here as many hospital systems (e.g. Value-Based Care) and physician groups (e.g., MIPS, ACOs) are increasingly focused on risk-adjusted “quality” and cost efficiency measures that are dependent on our documentation and its subsequent coding. So, you will start to hear more about this and see queries for acute, chronic, and decompensated (acute on chronic) chronic hepatic failure in the near future.

Physician Terminology Versus Coding

Some terms physicians generally use around liver conditions are:

• Acute

  • Liver injury (+ Acute) without specifying its underlying cause*

  • Acute Liver Failure

  • Fulminant Liver Failure (without specifying acuity)

  • Drug-Induced Liver Injury*

  • Obstructive Jaundice

  • Ischemic Liver Injury* / “Shock Liver”

  • Congestive Hepatopathy*

  • Alcoholic Hepatitis

  • Acute Viral Hepatitis

  • Hepatic Encephalopathy

  • “Transaminitis”*

• Chronic

  • Chronic Liver Disease (Ex: Hepatic Steatosis/Fatty Liver Disease, Chronic Viral Hepatitis)

  • Cirrhosis

    • Compensated (codes only as cirrhosis)

    • Decompensated (codes only as cirrhosis)

    • (not an exhaustive list)

Acute Liver Failure Versus Chronic

Physicians often reserve the term “liver failure” for only “acute liver failure” for patients without pre-existing liver disease who develop an acute liver injury with elevated LFTs (liver function tests), coagulopathy (INR >1.5), and acute hepatic encephalopathy. If the patient does not have those findings, especially encephalopathy, then the disease process is typically described by its acute condition (acute viral hepatitis, acute drug-induced liver injury, etc).

Otherwise, chronic conditions are listed by their chronic disease states but the term “failure” is typically not documented. The closest term to “chronic hepatic failure” physicians use is cirrhosis which is divided into:

• Compensated = No complications

• Decompensated = With complications (variceal bleeding, ascites, hepatic encephalopathy, hepatocellular carcinoma, etc.)

And coding?

For the chronic disease states such as viral hepatitis or fatty liver disease, there are individual codes for those.

For compensated cirrhosis, there’s cirrhosis codes with the underlying etiology.

BUT there is no code for “decompensated cirrhosis” and therefore this is generally captured by a cirrhosis code plus its associated complication (such as portal hypertension, ascites, etc.). Interestingly enough, “hepatic insufficiency” and “end-stage liver disease” are classified as chronic hepatic failure while “decompensated cirrhosis” is not. That’s just the way ICD-10-CM handles it.

The problem

The problem is that “chronic hepatic failure without coma” (e.g. K72.10) is a common diagnosis that highly impacts quality risk-adjusted metrics and HCCs (which i discussed in previous newsletters) which add to the severity of the underlying liver disease (e.g. alcoholic cirrhosis) or defined consequences (e.g. portal hypertension, esophageal varices).

Yet, while many of our patients have chronic hepatic failure, physicians are almost never going to document it unless they’ve been instructed to do so. So, our care will look worse “on paper” than in reality unless we address this.

Defining Chronic Hepatic Failure

If you asked most clinicians they’d likely equate “chronic hepatic failure” with “decompensated cirrhosis.” But, again, compensated and decompensated cirrhosis cannot be coded as hepatic failure.

Many hepatologists use the Child-Pugh classification which uses scores ranging from 5 to 15 to stage chronic liver disease as follows:

• Score 5 - 6 = Child-Pugh Class A

• Score 7 - 9 = Child-Pugh Class B

• Score 10 - 15 = Child-Pugh Class C

Per this UpToDate article, functional compromise starts at Child-Pugh Class B.

Per the 2023 Guidance on Hepatitis C, “Patients with a Child-Pugh score >7 have decompensated cirrhosis.” So, this gives us an evidence-based objective definition of chronic hepatic failure in patients with a Child-Pugh Class B score >7.

For those who want to argue for a more conservative definition, per the ICD-10-CM classification noted before, when a physician documents “End-Stage Liver Disease” it allows a coder to code “chronic hepatic failure.” As Child-Pugh Class B has a two-year survival rate of 60%, some may argue that’s not exactly “end-stage.” So, they may not feel comfortable equating Class B to chronic hepatic failure. But a 35% two-year survival rate with Class C (score >10) would almost certainly check that box.

Additionally, Dr. Kennedy has some thoughts on acute and acute on chronic hepatic failure:

Neither myself nor Dr. James Kennedy are official sources of guidance and you should defer to your institution’s clinical definitions and provider’s clinical judgment and documentation of these diseases. You may consider discussing this with a hepatologist.

Have some thoughts on this? Comment on my post about today’s newsletter on LinkedIn or Twitter (X)!

That’s all for now. Don’t hesitate to ask questions as they help inspire future issues!

Cheers,

Robert

Thanks again to Dr. James Kennedy, Dr. Steven Young, and additionally to Laura Samson, RN BSN CCDS for editing this newsletter!

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