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Z94.4
ICD-10-CM
Liver Transplant Status

Find comprehensive information on Liver Transplant Status diagnosis, including clinical documentation requirements, medical coding guidelines (ICD-10-CM, SNOMED CT), and post-transplant care. Learn about pre-transplant evaluation, recipient and donor criteria, surgical procedures, immunosuppression protocols, and complications management. This resource provides valuable insights for healthcare professionals, coders, and patients seeking information on liver transplantation.

Also known as

Post-Liver Transplant
Liver Graft Status

Diagnosis Snapshot

Key Facts
  • Definition : Replacement of a diseased liver with a healthy one.
  • Clinical Signs : Jaundice, fatigue, abdominal swelling, nausea, itching.
  • Common Settings : Transplant centers, ICUs, hepatology clinics.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z94.4 Coding
Z94.81

Liver transplant status

Indicates the patient has received a liver transplant.

K70-K77

Diseases of liver

Covers various liver diseases that may necessitate a transplant.

T86.1

Complications of liver transplant

Includes complications arising after a liver transplant procedure.

Z98.89

Other specified postprocedural states

Encompasses other post-transplant conditions not classified elsewhere.

Code-Specific Guidance

Decision Tree for

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

Is the patient currently awaiting liver transplant?

  • Yes

    Code Z94.1 Liver transplant status, awaiting liver transplant

  • No

    Has the patient received a liver transplant?

Documentation Best Practices

Documentation Checklist
  • Liver transplant status: pre/post/eval
  • Date of transplant if applicable
  • Indication for transplant
  • Current graft function assessment
  • Immunosuppressant medications

Coding and Audit Risks

Common Risks
  • Unspecified Status

    Coding lacks specificity (e.g., pre-transplant, post-transplant, status unknown). Clarify with physician for accurate HCC capture and reimbursement.

  • Timing Confusion

    Inaccurate documentation of transplant date impacts coding and financial outcomes. CDI should query for clear timing information.

  • Complication Coding

    Missing or incorrect codes for transplant complications. Thorough review of documentation is crucial for accurate billing and quality reporting.

Mitigation Tips

Best Practices
  • Code transplant status using current ICD-10-CM guidelines.
  • Document pre- and post-transplant complications clearly.
  • Query physicians for clarification on unclear diagnoses.
  • Ensure accurate coding for compliant reimbursement.
  • Educate staff on liver transplant CDI best practices.

Clinical Decision Support

Checklist
  • 1. Verify MELD score documented
  • 2. Check UNOS status if listed
  • 3. Confirm pretransplant imaging reports
  • 4. Review transplant team consult note

Reimbursement and Quality Metrics

Impact Summary
  • Liver Transplant Status reimbursement hinges on accurate ICD-10-PCS coding (Z94.81, Z94.82, Z94.89) impacting DRG assignment and payment.
  • Coding quality directly affects CMI and reported transplant outcomes. Accurate status reporting is crucial for performance metrics.
  • Timely and specific coding of transplant status (pre/post, recipient/donor) minimizes claim denials and optimizes revenue cycle.
  • Accurate liver transplant status coding supports risk adjustment models and quality reporting initiatives for transplant centers.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the key post-liver transplant complications to monitor for in the immediate, intermediate, and long-term periods?

A: Managing post-liver transplant complications requires vigilant monitoring across different timeframes. In the immediate post-operative period (first few weeks), primary concerns include primary graft non-function, hepatic artery thrombosis, portal vein thrombosis, biliary complications, and surgical bleeding. Explore how early detection and intervention can significantly impact patient outcomes in these critical early stages. The intermediate period (months 1-6) focuses on managing acute cellular rejection, opportunistic infections (e.g., CMV, EBV), and recurrence of the original liver disease. Consider implementing standardized immunosuppression protocols and infection prophylaxis strategies to mitigate these risks. Long-term complications (years after transplant) include chronic rejection, renal dysfunction, cardiovascular disease, and post-transplant lymphoproliferative disorder (PTLD). Learn more about long-term surveillance and management strategies to optimize graft and patient survival.

Q: How can I differentiate between acute cellular rejection and other causes of abnormal liver function tests (LFTs) in a liver transplant recipient?

A: Abnormal LFTs post-liver transplant can arise from various causes, including acute cellular rejection (ACR), drug toxicity (e.g., immunosuppressants), infections (e.g., viral hepatitis), biliary complications, and recurrence of the original liver disease. Differentiating ACR requires a multi-pronged approach. Serial LFT monitoring, including AST, ALT, ALP, GGT, and bilirubin, can provide initial clues. However, liver biopsy remains the gold standard for diagnosing ACR and grading severity. Consider integrating imaging studies like Doppler ultrasound and MRI to assess vascular flow and identify potential biliary complications. Furthermore, analyzing immunosuppression levels and screening for infections can further refine the diagnosis. Learn more about the utility of advanced diagnostic tools like gene expression profiling to enhance the accuracy and timeliness of ACR diagnosis.

Quick Tips

Practical Coding Tips
  • Code status post liver transplant
  • ICD-10-PCS Z94.81
  • Document transplant details
  • CPT consult/follow-up codes
  • Query physician for clarity

Documentation Templates

Patient presents for follow-up regarding liver transplant status.  The patient underwent orthotopic liver transplantation (OLT) on [Date of Transplant] due to [Original Liver Disease, e.g., end-stage liver disease secondary to hepatitis C].  Current immunosuppression regimen includes [List Medications with Dosage and Frequency, e.g., tacrolimus 1 mg twice daily, mycophenolate mofetil 500 mg twice daily].  Patient reports [Symptoms, e.g., no fever, chills, or abdominal pain].  Physical examination reveals [Findings, e.g., stable vital signs, well-healing surgical scar, no jaundice, abdomen soft and non-tender].  Laboratory results including liver function tests (LFTs), complete blood count (CBC), and comprehensive metabolic panel (CMP) are reviewed and show [Specific Results with Units and Normal Ranges, e.g., AST 25 U/L (normal range 8-48 U/L), ALT 30 U/L (normal range 7-55 U/L), total bilirubin 0.8 mg/dL (normal range 0.1-1.2 mg/dL)].  These findings suggest [Interpretation of Results, e.g., stable graft function].  Immunosuppressant levels are within therapeutic range.  The patient is compliant with medications and follow-up appointments.  The patient was educated on the importance of continued adherence to the immunosuppressive regimen, monitoring for signs of rejection, and reporting any new or worsening symptoms.  Plan of care includes continued immunosuppression with [Medications], routine laboratory monitoring including LFTs, CBC, CMP, and immunosuppressant levels, and follow-up in [Time Frame, e.g., 3 months] for ongoing assessment of liver transplant status.  Diagnosis: Liver transplant status, post-transplant.  Prognosis: Good with continued adherence to treatment plan.  Potential complications discussed include organ rejection, infection, and medication side effects.
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