Liver Injury Due to Drugs

bbogda@morrishospital.org

Good Afternoon.
We have a patient who has rheumatoid arthritis and ulcerative colitis being treated with Methotrexate and Leflunomide. 
Her liver function tests are all elevated.  The doctor writes:

76-year-old white female with longstanding history of rheumatoid arthritis, maintained on methotrexate baseline, currently with recent addition of Arava (leflunomide) with multiple side effects currently including drug-induced liver injury and secondary abnormal liver chemistries, trending downwards currently.

The advice in this coding clinic has me a little confused.  Do you think in this case I should clarify for acute hepatitis, or go for the acute/subacute liver failure, or is there another ICD-10 code more appropriate?

AHA Coding Clinicâ for ICD-10-CM and ICD-10 PCS, 2Q 2015, Volume 2, Number 2, Page 17 

Question:

 The patient was diagnosed with acute liver injury as well as acute hepatitis, nonviral. Code S36.119, Unspecified injury of liver, does not seem to apply since there was no documentation of a traumatic injury to the liver. How should nontraumatic acute liver injury be coded? 

Answer:

Code the exact nature of the liver problem, if known. If the etiology of the liver injury is not clearly documented, query the provider for clarification. 

For this example, assign code K72.00, Acute and subacute hepatic failure without coma, for non-viral acute hepatitis.

In ICD-10-CM there is no Index entry for “acute hepatitis, nonviral.” However, the Alphabetic Index, under the term “Hepatitis” leads to code K75.9, Inflammatory liver disease, unspecified. Code K75.9 has an Excludes 1 note: acute or subacute hepatitis (K72.0-).

Thanks for your help,

Betty

evanspx@sutterhealth.org

Brief response.  I believe you should research references for ‘acute liver failure’ caused by drugs. If the record has clinical support, I’d consider a query to that effect.  

Paul Evans, RHIA, CCDS

evanspx@sutterhealth.org

Search for ‘acute liver failure’ NEJM has a good reference online.  

bbogda@morrishospital.org

Thank Paul - I will check it out.

evanspx@sutterhealth.org

Most welcome..let us know what you think?  We have some cases here with fulminant liver failure due to medications and/or mushrooms.   Notable that those with this form of acute failure due to mushrooms very often die here very quickly.  Staff will sometimes use the term ‘injury’ and this can lead to classification issues.

Jane.Brown@ensemblehp.com

There are also great resources on Up to Date regarding drug induced liver injury.  On a personal note, I have had a family member and a close friend diagnosed with drug induced liver injury in the past year.  One was due to an off label use of a medication that had anecdotally been shown to help the condition, and the other was due to an anesthesia medicine. Both individuals are extremely healthy otherwise with strict attention to diet and exercise, so this can be seen for a variety of reasons. 

evanspx@sutterhealth.org

Unfortunately, some people in California find and eat different mushrooms.  I have reviewed charts in which entire families die in a matter of day as a result of ingesting the ‘death-cap’ mushroom. They present with liver enzymes off the charts and the livers are essentially destroyed at the time of admit w/o hope for recovery.

It is also surprising that using even just a bit more OTC pain-relievers may also cause Fulminant Acute Liver Failure.  When the acute liver failure is present, the term ‘acute injury’ may cause confusing and result in misclassification.  Hence, this discussion about “injury’ versus ‘fulminant, acute failure’.