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K76.0
ICD-10-CM
Fatty Infiltration of the Liver

Understanding Fatty Liver (Hepatic Steatosis) diagnosis, including Non-Alcoholic Fatty Liver Disease (NAFLD), requires accurate clinical documentation for optimal medical coding. This resource provides information on Fatty Infiltration of the Liver, covering key aspects relevant to healthcare professionals and coders seeking clarity on this condition, often identified by the letter F. Learn about diagnosis, documentation, and coding best practices for fatty liver disease.

Also known as

Fatty Liver
Hepatic Steatosis
Non-Alcoholic Fatty Liver Disease (NAFLD)
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Excess fat buildup in the liver, often linked to obesity and metabolic syndrome.
  • Clinical Signs : Usually asymptomatic, but can cause fatigue, right upper quadrant pain, and abnormal liver tests.
  • Common Settings : Primary care, gastroenterology, endocrinology, weight management clinics.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC K76.0 Coding
K75.8

Other specified liver diseases

This code encompasses various specific liver conditions, including fatty infiltration.

K76.0

Fatty liver, not elsewhere classified

This code specifically refers to fatty liver disease not due to alcohol.

K70-K77

Diseases of liver

This broader range includes all types of liver diseases, including fatty liver.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the fatty liver alcohol-related?

  • Yes

    Code as K70.0 Alcoholic fatty liver

  • No

    Is there inflammation/injury?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Excess fat buildup in the liver.
Liver inflammation due to fat buildup, often with fibrosis.
Advanced scarring of the liver due to NASH.

Documentation Best Practices

Documentation Checklist
  • Document liver enzyme levels (ALT, AST).
  • Describe ultrasound or imaging findings.
  • Specify alcoholic vs. non-alcoholic etiology.
  • Note presence/absence of NASH or fibrosis.
  • Record patient's BMI and relevant metabolic risk factors.

Coding and Audit Risks

Common Risks
  • Unspecified Etiology

    Coding NAFLD without specifying alcoholic vs. non-alcoholic impacts severity and reimbursement.

  • Clinical Validation

    Liver imaging findings should support the diagnosis for accurate coding and audit defense.

  • Comorbidity Capture

    Associated conditions like diabetes, obesity, and metabolic syndrome must be documented and coded.

Mitigation Tips

Best Practices
  • ICD-10 K76.0, CDI: Document alcohol use, BMI, diet, exercise.
  • CPT 99213-99215: Assess metabolic risk factors, order LFTs.
  • HCC coding: Capture NAFLD severity for accurate risk adjustment.
  • Encourage weight loss, healthy diet, regular exercise for NAFLD.
  • Monitor liver enzymes, offer diabetes, hyperlipidemia management.

Clinical Decision Support

Checklist
  • 1. Elevated ALT/AST? ICD-10: K76.0 Document alcohol use.
  • 2. Imaging (ultrasound/MRI) shows steatosis? CPT 76700/74183
  • 3. Exclude other liver diseases (viral, autoimmune). Document.
  • 4. Assess metabolic risk factors (obesity, diabetes). ICD-10: E66.9, E11.9

Reimbursement and Quality Metrics

Impact Summary
  • ICD-10-CM Coding: K76.0 impacts MS-DRG assignment and reimbursement.
  • Accurate HCC coding for risk adjustment and RAF score calculations.
  • Quality metrics: Monitoring of NAFLD diagnosis and management affects hospital performance.
  • Denial management: Precise coding and documentation crucial for avoiding claim denials.

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Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective diagnostic strategies for differentiating between simple steatosis and non-alcoholic steatohepatitis (NASH) in patients with suspected fatty liver disease?

A: Differentiating simple steatosis from NASH, a more aggressive form of fatty liver disease, requires a multi-pronged approach. While liver biopsy remains the gold standard, it's invasive. Non-invasive strategies are increasingly preferred and include serum biomarkers like the Enhanced Liver Fibrosis (ELF) test or the FibroTest, along with imaging modalities such as transient elastography (FibroScan) and controlled attenuation parameter (CAP) measured by ultrasound. These tools can assess liver stiffness and steatosis grade, helping stratify patients and guide treatment decisions. Explore how combining serum biomarkers with imaging can improve diagnostic accuracy and minimize the need for biopsy in your practice.

Q: How can I effectively manage a patient with newly diagnosed NAFLD, considering both lifestyle interventions and pharmacological therapies based on current clinical guidelines?

A: Managing newly diagnosed NAFLD begins with lifestyle interventions targeting the underlying metabolic drivers. Weight loss of at least 7-10% through a balanced diet and regular exercise is the cornerstone of treatment. Clinicians should counsel patients on limiting fructose intake, emphasizing a Mediterranean-style diet rich in fruits, vegetables, and whole grains, and recommending at least 150 minutes of moderate-intensity aerobic activity per week. For patients with persistent NASH or advanced fibrosis despite lifestyle changes, pharmacological therapies like Vitamin E, pioglitazone, and GLP-1 receptor agonists are being investigated. Consider implementing a structured lifestyle intervention program in your clinic and learn more about the evolving role of pharmacotherapy for NAFLD management according to the latest clinical practice guidelines.

Quick Tips

Practical Coding Tips
  • Code K76.0 for simple steatosis
  • ICD-10-CM K75.0 for alcohol-related
  • Document NASH severity for K75.8
  • Query physician for etiology specifics
  • Consider Z72.4 for alcohol risk

Documentation Templates

Patient presents with suspected fatty liver disease, also known as hepatic steatosis or non-alcoholic fatty liver disease (NAFLD).  Clinical findings suggestive of fatty infiltration of the liver include elevated liver enzymes (ALT, AST), possible hepatomegaly on physical exam, and complaints of fatigue or right upper quadrant discomfort.  Patient denies significant alcohol consumption, making NAFLD the primary differential diagnosis.  Ultrasound imaging of the liver is ordered to assess for steatosis and rule out other potential causes of liver dysfunction such as cirrhosis or hepatitis.  Differential diagnoses considered include alcoholic fatty liver disease, viral hepatitis, autoimmune hepatitis, and metabolic syndrome.  Initial treatment plan focuses on lifestyle modifications including weight loss through diet and exercise, management of hyperlipidemia and diabetes if present, and avoidance of hepatotoxic medications.  Patient education regarding the importance of these interventions in managing NAFLD and preventing progression to non-alcoholic steatohepatitis (NASH) and fibrosis is provided.  Follow-up appointment scheduled to monitor liver function tests and assess response to therapy.  ICD-10 code K76.0 will be considered pending imaging results.  Further evaluation and management may include referral to a hepatologist if indicated by disease progression or lack of response to initial therapy.
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