Find comprehensive information on Primary Biliary Cholangitis diagnosis, including clinical documentation, medical coding, ICD-10 codes K73.1, and relevant healthcare resources. Learn about PBC symptoms, liver function tests LFTs, AMA antibodies, and treatment options. This resource offers guidance for healthcare professionals on accurate PBC diagnosis coding and best practices for patient care documentation. Explore resources related to biliary tract disease, cholestatic liver disease, and autoimmune hepatitis for a thorough understanding of PBC.
Also known as
Primary biliary cholangitis
Chronic autoimmune liver disease affecting bile ducts.
Diseases of liver
Covers various liver conditions, including inflammation and cirrhosis.
Disorders of gallbladder, biliary tract
Includes conditions affecting bile storage and flow, like gallstones.
Systemic connective tissue disorders
Autoimmune diseases sometimes associated with PBC.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis Primary Biliary Cholangitis?
Yes
Is there cirrhosis?
No
Do not code as Primary Biliary Cholangitis. Review the clinical documentation for alternative diagnosis.
When to use each related code
| Description |
|---|
| Primary Biliary Cholangitis |
| Primary Sclerosing Cholangitis |
| Autoimmune Hepatitis |
Coding PBC without staging (K74.3) when clinical documentation supports a specific stage (K74.4, K74.5) leads to undercoding and lost revenue.
Incorrectly coding overlapping symptoms (e.g., pruritus, fatigue) separately when they are manifestations of PBC can trigger audits and denials.
Failure to capture and code associated conditions like osteoporosis or autoimmune hepatitis with PBC can impact risk adjustment and quality metrics.
Patient presents with complaints consistent with possible primary biliary cholangitis (PBC). Symptoms reported include fatigue, pruritus, and right upper quadrant discomfort. Patient denies jaundice, fever, or chills. Physical examination reveals hepatomegaly with mild tenderness on palpation. Skin examination shows evidence of xanthelasma. Laboratory findings demonstrate elevated alkaline phosphatase, elevated gamma-glutamyl transferase (GGT), and the presence of antimitochondrial antibodies (AMA). Liver function tests (LFTs) show elevated bilirubin and aspartate aminotransferase (AST). Ultrasound of the abdomen revealed no biliary obstruction. Diagnosis of primary biliary cholangitis is suspected based on the clinical presentation, serological markers, and imaging findings. Differential diagnoses include primary sclerosing cholangitis (PSC), autoimmune hepatitis, and drug-induced liver injury. Plan includes further evaluation with liver biopsy to confirm the diagnosis and stage the disease. Treatment will be initiated with ursodeoxycholic acid (UDCA) for management of cholestasis and symptomatic relief. Patient education provided regarding PBC, its progression, and the importance of medication adherence. Follow-up appointment scheduled to review biopsy results and assess response to therapy. ICD-10 code K74.3 assigned. Referral to hepatology specialist considered. Patient advised to report any worsening symptoms, such as jaundice, dark urine, or light-colored stools.