Budd-Chiari Malformation Type 1

I have a patient who was admitted with abdominal pain due to  small bowel obstruction.  Budd-Chiari malformation Type 1 is noted in her H/P PMH.

A review of her past records reveals that she was seen in May of 2017 in the ED for vaso-vagal syncope (was not admitted) and then had an MRI which revealed :

Cerebellar tonsils extending to 12 mm below foramen magnum consistent with Chiari I type malformation.   

I am not sure if the Budd-Chiari should be coded or not, since there are no current symptoms, treatment or monitoring.  There is not a 'chronic' option and code G93.5 is an mcc. I do believe we code asymptomatic PFOs which I have always wondered about too.  What do others do?


  • To report a secondary diagnosis it must as you identify demonstrate an element of treatment to include at least one of the following- clinical evaluation, therapeutic treatment, further evaluation by diagnostic studies, procedures, or consultation, extend the patient's length of hospital stay. or require  Increased nursing care. If you are not seeing that any of these conditions are met you are right to question if it is appropriate to report. 

    Budd Chiari can be incidentally found, without any symptoms and not of concern. If it is not clear as to the significance of the diagnosis I would likely query the provider to better clarify its significance. since the patient was admitted with abdominal pain the provider might have considered this as a possible etiology until the obstruction was identified. If it is considered a chronic issue and was evaluated- you may have support to report. 

    I also searched AHA Coding Clinics for any advice and did not find any direction related to Budd Chiari. . 
    There is an ICD-9 CM Coding Clinic related to PFOs- Coding Clinic, Third Quarter 2009 Page: 17.
    this states that if the PFO was evaluated it could be reported. 
  • Thank you Laurie, I did not find anything on my search either.  Thanks for confirming my thoughts.
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