Question

A patient is admitted because of congestive heart failure (CHF). During the treatment of the CHF the patient was also found to have elevated liver function tests. The physician worked up the elevated liver function tests but was not able to determine a diagnosis with regard to the abnormal liver tests. The coder should identify the following diagnosis(es) when coding the record:

-Congestive heart failure with liver disease
-Abnormal liver function tests
-Congestive heart failure and a code from the findings abnormal section
-Congestive heart failure

Answer 1

For a patient admitted with congestive heart failure and elevated liver function tests without a specific liver disease diagnosis, the medical record should be coded with a diagnosis of congestive heart failure and a code for abnormal liver function tests.

Step-by-step explanation:

When a patient with congestive heart failure (CHF) is also found to have elevated liver function tests, the patient's medical record should be coded to accurately reflect these conditions. The coder should include a diagnosis of congestive heart failure because it is the confirmed diagnosis. Since there is an abnormality in liver function tests but no definitive diagnosis of a liver disease, the coder should also include a code for the abnormal liver function test results. It is essential not to assign a diagnosis code for liver disease without a clear diagnosis by the physician.

This approach ensures that medical billing and lab test ordering can proceed correctly, with potential relevance to management strategies that need to be undertaken given an abnormal liver panel. These tests often include parameters like alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and albumin levels, among others, that can indicate liver dysfunction possibly secondary to heart failure or another underlying condition.