Coding, Classification & Reimbursement



    Posted 04-20-2017 10:49

    We need clarification on which ICD 10 code should be used for the following diagnoses.  There seems to be controversy as to how to classify these which leads to a variety of coding choices.  Please include the justification used to determine why a specific code is better than the other options. 


    Elevated LFTs  (Liver Function Tests)

    Elevated TSH (Thyroid Stimulating Hormone)

    Elevated Troponin

    Elevated Bilirubin

    • Are these all considered Blood Chemistry Abnormal Findings? 
    • Are the LFTs considered Serum Enzymes or a Function Study? 
    • Is Troponin considered an Enzyme or Plasma Protein? 
    • What tests are considered Function Studies – only radiology or can certain laboratory exams lumped under this as well?
    • Does an Elevated Bilirubin automatically indicate Jaundice   

     Any input appreciated.




    Posted 03-11-2018 10:51
    I would love to see an answer to this question.
    I do see that it is an area of coding that is very confusing to coders.
    Here is a link to a similar question:
    Coding, Classification and Reimbursement

    Thank you

    Nancy Alexander
    Medical Record Auditor



    Posted 06-11-2019 07:24
    I'm also interested in seeing what others are using.  Since it's been a year, what have you decided to use?

    Kay Piper, RHIA, CDIP, CCS
    Inpatient Coding Educator
    SSM Health - St. Louis, MO


    Posted 06-12-2019 03:05
    Edited by Andrea Wong 06-12-2019 03:05
    This topic is something that I've had go back and forth in my head, but with persistent reading/research, I've come to some form of resolution on how I've decided to code a few of the issues mentioned above.

    Elevated LFTs  (Liver Function Tests)  & Elevated Bilirubin

    -I've come to the personal conclusion that you can use "R94.5 - Abnormal results of liver function studies" when abnormal LFT's/ Abnormal Liver function panels are not specified. I read a case study by Nelly Chisen (the Editor of the AHA Coding Clinic) in the book called "ICD-10-CM and ICD-10 PCS Coding Handbook for 2018." Although, this textbook is not an official coding clinic publication, the book is very insightful and offers consistent advice with its coding clinics and updated annual guidelines.

    [REFERENCE: In case summary exercises for Chapter 8-Digestive System, page 615, Case #14: "An excisional needle biopsy of the liver was performed due to an abnormal liver function studies times 3. The pathology indicated that the liver tissue was normal. Discharge Diagnosis #3.) Abnormal liver function studies."
    Answer: R94.5 - Abnormal results of liver function studies
    Comments section: "Although the biopsy of the liver was normal, the physician still indicated that there was an abnormality in the liver function lab studies, so this was coded."]

    The rationale specifically mentioned "lab studies" in the application of the R94.5 code, so I personally use that code when a physician mentions abnormal laboratory liver function tests and there is no specific liver enzyme identified or stated, and multiple laboratory liver function tests were performed, just like the case. When the physician does mention a specific enzyme, I code it to the specific enzyme identified such as the type of elevated transferase, alkaline phosphatase, lactate dehydrogenase, bilirubin, etc. The only time I would use the elevated liver function "test" default code (R79.89 – Other specified abnormal findings of blood chemistry) is if there was an other specified or unspecified finding for a singular liver function test. Elevated liver function tests for bilirubin defaults to the symptom code R17 - Jaundice, unspecified. If the physician doesn't document a specific type of jaundice, or a specific type of hyperbilirubinemia, than R17 would be my default code since the main-term hyperbilirubinemia doesn't have a default code even though they are virtually synonyms.

    Because R94.5 is under the tabular section titled, "Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90-R94), I can understand why there are lots of uncertainty regarding using the code when elevated LFT is stated. Category R94 has includes note for radioisotope uptake studies, and abnormal results of scintigraphy making the coder second guess themselves. After reviewing other body system codes at the 6th character level, it appears that the R94- category is applied for a wide spectrum of functional tests, whether it be a bladder function test, an ECG, a ventilatory capacity test, or using nuclear imaging.

    I want to point out that the Official Coding Conventions state that "INCLUSION TERMS indicate some of the conditions for which that code number may be used… The inclusion terms are not exhaustive. The index may also provide additional terms that may be assigned to a given code." Just because there is no mention for testing of blood levels does not preclude the assignment from this category. The only way to know for sure is to confirm with the AHA coding clinic, but again, it appears based on the example above, that we can use it based on abnormal lab studies.

    In summary:


    -Elevated Single Liver function test – If unspecified/Other finding - use code R79.89

    -Elevated Single Liver function test – If specified serum enzyme/bilirubin– use the specified code such as R74.0, if elevated SGOT (transaminase) documented.

    -Elevated Multiple tests– If unspecified elevated liver function tests – use code R94.5

    -Elevated Multiple tests – If specified significance of any particular serum enzyme/bilirubin – use the specified serum enzyme/bilirubin elevation such as R74.0, if elevated SGOT (transaminase) documented.

    -Abn Radiological/ Nuclear Liver functional studies – use code R94.5

    Elevated TSH (Thyroid Stimulating Hormone)
    -Is always considered clinically significant, and is an indicator for Hypothyroidism, especially if pt is taking levothyroxine or other Rx to indicate, perhaps that's why there isn't a specific code. May suggest a query.

    -If a query isn't possible, one would think that if Nelly Chisen applied a code for liver function studies related to laboratory, than why couldn't it be applied for laboratory workup on the thyroid? Index: Abnormal > function studies > thyroid > R94.6 – Abnormal results of thyroid function studies.

    Elevated Troponin
    -Coded definitively as R74.8 – Abnormal levels of other serum enzymes.

    -        Index: Abnormal > serum level (of) enzymes > R74.8 – Tabular: There is a note for "tip – Assign for documented abnormal or elevated troponin level when a definitive diagnosis has not been established."

    -        Also, when I've used OptumCAC (encoder) software, elevated troponin consistently leads to code R74.8, so I go with that code.
    Andrea Wong


    Posted 06-12-2019 07:30
    Hello All,

    Andrea, you seem to share the quest to research thoroughly your coding like I do. Upon reading this post, I dug out an old electronic sheet I made when I performed ED coding and compared with what you posted. I liked the references you chose to use in your research. I assumed by you citing Optum that you used an Optum ICD-10 book. I toggle every other year between Optum and AMA coding books. Like you, I tear up the coding asphalt when looking for answers because a big part of my job performance is communicating results/findings of coding discrepancies. Finding and using credible citations can be difficult at times. Andrea, your willingness to tackle this topic shows you like to meet the challenges of coding. Very admirable!

    I wanted to add something. Thyroid. Query. One would not need to query a provider for clarification. Reason: TSH function tests are indicative and mostly lead to some type of disorder/disease. Providers are very aware how important it is to diagnose a thyroid condition/disease when they order tests for thyroid function and the result is abnormal. As a coder, I would look for a definitive diagnosis documented by the provider, previous/current medication, additional workup, referral/consult, etc. before coding a CH18 code. Seldom have I coded CH18 code when there is no specified condition to report on Inpatient. When I performed ED coding, yes, coded this all the time. The function of the ED is to restore or support (or both). They perform many tests for function/status of organ systems and blood. If ED can't r and s, then they consult, refer to o/p or admit.

    I remember researching this topic extensively for symptoms, diseases and conditions involving the thyroid. From what I synthesized of the materials and references, studies, and so forth, the conclusion to me was obvious there wasn't a specific code for a reason. Too easy for coders to use it as a "dump" code and move on. Part of our jobs is understanding disease processes and we must rely on provider documentation to report accurate codes. If the provider documentation is not clear, then there is need for additional training to assist the provider in documentation skills for ICD-10 code set. The use of query, in my opinion, should not be used loosely as providers become numb to this and may even have a negative impact for coders. I have always employed a different approach. I hide these documentation inconsistencies within the premise of training the provider(s). Seems to work better as I see the results when auditing future records. However, when there is need for a query, then I make it a point to construct a non-leading inquiry to clear up documentation or I report my audit findings and let CDI take it from there.

    Ch18 Guidelines for Inpatient and the use of UHDDS guidelines was a real eye opener for me!

    Happy Coding!

    Kelly Randell
    Inpatient Auditor


    Posted 07-01-2019 20:04
    Update: There is now closure regarding how to code “elevated troponin” per coding clinic, 2nd quarter, 2019 advised to code it as R79.89- Other specified abnormal findings of blood chemistry.

    This is not coded as abnormal level of serum enzymes per my previous mentioned findings.

    Andrea Wong


    Posted 07-02-2019 14:37
    Thanks for the update Andrea.

    Our organization doesn't receive via 3M our coding clinics until after Oct of every year. I wish we got ours concurrently like everyone else. I looked at my sheet I maintain, for coding conditions signs and symptoms, like this and what I had for R79.89 was "Grey Zone Troponin" if that helps any.

    Have a great day

    Kelly Randell
    Inpatient Auditor