Topic: Acute Liver Failure
H&P: 52-year-old male presents to the ER with change in mental status and abdominal pain per family. Family also reports drowsiness, weakness, and fatigue. Unable to eat or drink due to abdominal pain, nausea, and vomiting. Reports occasional alcohol use, and Tylenol twice daily for arthritic pain.
- PMH: Hypertension, Hyperlipidemia, DM2, osteoarthritis bilateral knees
- Home Medications: Lipitor 20mg PO QD; Lisinopril 5mg; Insulin Humalog
- Vitals: P:85; BP 196/92; RR: 18; Temp 38.8; BMI 38.6
- PE: Obese patient; soft abdomen, but RUQ tender to palpitation; no peripheral edema; clear lungs, no wheezing, denies cough, fever; heart sounds S1 and S2
- Labs: WBC 10.3; RBCs: 3.8; Hgb: 12.2; Hct: 38; Platelets: 50; Glucose 76; Sodium 129; Potassium: 3.2; Bilirubin:1.9; Ammonia: 80; INR: 2.0; Creatinine 2.5
- CT: Abd CT: enlarged liver, spleen
- GI Consult: Liver failure, unsure cause, plan liver biopsy
- Liver Biopsy Pathology: autoimmune hepatitis
- Discharge Summary: Liver failure; AMS; AKI, hypertension, hyperlipidemia, DM type 2
- Discharge Medication: Prednisone 40 mg daily, follow up with GI ASAP, sustain from alcohol and Tylenol until cleared by GI. Resume home meds: Lipitor 20mg; Lisinopril 5mg; Insulin-prior dose
Question: Are there query opportunities based on the scenario stated above?
Discussion:
Patient presents with signs/symptoms of liver failure and found to have autoimmune hepatitis. There are many opportunities for clarification.
Diagnostic criteria for acute liver failure:
- Signs and symptoms-fatigue, malaise, lethargy, anorexia, nausea, vomiting, pruritis, and RUQ pain. May also have jaundice, ascites, and mental status changes.
- Prolonged prothrombin time with INR >/= 1.5
- Elevated aminotransferase levels (often with abnormal bilirubin and alkaline phosphatase levels)
- Elevated bilirubin level
- Low platelet count (</= 150)
- Hepatic encephalopathy
Treatment for acute liver failure:
- Identify etiology-may influence treatment
- Liver biopsy
- Transplant may be necessary if irreversible
- Manage any associated complications such as AKI, GI bleed, respiratory failure, etc.
UASI Recommends:
- Query for acuity and etiology of the Liver Failure
- Query for Hyponatremia
- Query for Thrombocytopenia
- Query for etiology of Kidney Failure/Injury
Documentation Without Clarification:
- Principal Diagnosis: Liver failure (K72.90)
- Secondary Diagnosis: Essential HTN (I10), Type 2 diabetes mellitus without complications (E11.9), Hyperlipidemia (E78.5), Altered mental status (R41.82), Acute kidney injury (N17.9)
- Working DRG: 442-Disorders of the Liver except malignancy, cirrhosis, alcoholic hepatitis w/CC RW: 0.9334 GLMOS: 3.2 SOI/ROM: 3/2
Documentation With Clarification:
- Principal Diagnosis: Acute and subacute hepatic failure without coma (K72.00)
- Secondary Diagnosis: Hyponatremia (E 87.1), Thrombocytopenia (D69.6), Hepatorenal syndrome (K76.7), Autoimmune hepatitis (K75.4), Essential HTN (I10), Type 2 diabetes mellitus without complications (E11.9), Hyperlipidemia (E78.5)
- Working DRG: 441-Disorders of the Liver except malignancy, cirrhosis, alcoholic hepatitis w/ MCC RW: 1.8505 GLMOS: 4.7 SOI/ROM: 3/4
CDI Educational Tips:
Coding Considerations:
- AHA Coding Clinic, Second Quarter 2015, p. 17-if documentation of “acute liver injury” does not clearly identify the etiology, a query should be placed.
- AHA Coding Clinic, Second Quarter 2014, p. 13-Documentation of “shock liver” is reported to K72.0-Acute and subacute hepatic failure
- With hepatic failure and documentation of encephalopathy, it defaults to “without coma”. If the patient exhibits signs and symptoms of coma, a query may need to be placed to clarify.
- Monitor renal function closely on these patients. 30-70% of patients will have hepatorenal syndrome.
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.