CDI Solutions  •  Tips & Friendly Reminders  •  Liver Failure

Topic: Liver Failure

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Definition

A severe condition that is characterized by the rapid deterioration of liver function when the liver is damaged and not able to function properly. It can be classified as acute liver failure (ALF) and/or chronic liver failure.

Acute Liver Failure

Defined by the American Gastroenterological Association as a rare, acute, and potentially reversible condition that results in severe liver impairment and rapid clinical deterioration. Characterized by the presence of coagulopathy (INR ≥1.5) in patients without cirrhosis or pre-existing liver disease and any degree of mental status alteration (encephalopathy) within 26 weeks of the onset of illness. Common causes include drug-induced liver injury (e.g., acetaminophen toxicity), viral hepatitis, malignancy, sepsis, and severe hypotension.

Chronic Liver Failure

Most common and typically results from progressive liver damage over months to years, often due to chronic liver diseases such as cirrhosis, hepatitis B or C, alcoholic liver disease, or non-alcoholic fatty liver disease (NAFLD).

Acute conditions associated with decompensated cirrhosis

Hepatic encephalopathy Variceal bleeding — esophageal, gastric Portal hypertension Ascites Hepatorenal syndrome
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Diagnostic Criteria

Definitive criteria for acute hepatic failure: INR ≥ 1.5 that is prolonged and progressively increases.

Lab tests typically abnormal in acute and chronic liver failure

  • ▸ Aminotransferase (AST & ALT) > 3 × URL
  • ▸ Elevated bilirubin
  • ▸ Low platelet count (< 150K)
  • ▸ Other possible abnormalities: elevated creatinine, amylase, lipase, GGT, LDH, low albumin, anemia

Clinical presentation

Jaundice Ascites / edema RUQ / liver tenderness Encephalopathy

Treatment and management

  • ▸ Treat underlying cause and complications
  • ▸ Avoid hepatotoxic medications
  • ▸ N-acetylcysteine for Tylenol toxicity
  • ▸ Lactulose for hepatic encephalopathy
  • ▸ Vitamin K for coagulopathy
  • ▸ Liver transplantation remains the definitive treatment for patients with poor prognosis despite maximal medical therapy. Early evaluation for liver transplants is crucial, especially in cases with rapid deterioration.

Coding & CDI Considerations

DRG Assignment
Liver disease/failure as a principal diagnosis is assigned to two DRG triplets: 432–434 and 441–443.
  • ▸ If a patient is admitted for hepatic encephalopathy due to a chronic liver disease, the manifestation, encephalopathy, would be sequenced as the principal diagnosis.
  • ▸ Cirrhosis is not usually assigned the principal diagnosis unless the patient is admitted for surgery as it is a chronic condition.
  • ▸ “Carrier” of viral hepatitis codes to ‘chronic’ viral hepatitis.
  • ▸ K76.82 hepatic encephalopathy (acute, chronic, or unspecified) is a non-cc. Also assign the chronic liver disease.
  • ▸ K72.00 acute hepatic failure is an MCC. It includes acute/subacute hepatic failure, acute nonviral hepatitis and ischemic hepatitis.
  • ▸ K72.00 is not assigned if the acute hepatic failure is due to alcohol, drugs, viral hepatitis, or is postprocedural.
📚 Coding Clinics to Consider
AHA Coding Clinic · 2015 Q2, p. 17
Nontraumatic acute liver injury
AHA Coding Clinic · 2002 Q1, p. 3
Hepatic encephalopathy and alcoholic cirrhosis
AHA Coding Clinic · 2022 Q1, p. 52
Clarification: Toxic metabolic encephalopathy due to hepatic encephalopathy

Clinical pearls to keep in mind

⚠ INR & Coumadin: When evaluating a patient’s INR, always verify they are not on Coumadin. The therapeutic range of the INR on Coumadin is 2.0–3.0. This will not be indicative of hepatic failure.
⚠ Enzyme elevation: Mild to moderate elevation in liver enzymes can be common in otherwise healthy people. If a patient has chronic liver disease, the enzymes will be chronically elevated.
⚠ “Shock liver”: Also known as ischemic hepatitis. It is used to describe acute liver failure caused by severe hypotension, i.e. shock, and is often overlooked.

Query Opportunity

1
When patients are admitted with altered mental status from baseline, review the ammonia level. An elevated ammonia confirms the diagnosis of hepatic encephalopathy — query as necessary.
2
In patients with cirrhosis or ascites, when clinical indicators (e.g., fever, abdominal pain, worsening encephalopathy, renal failure) and ascitic fluid PMN > 250 are present, review for and query as necessary for spontaneous bacterial peritonitis (SBP) if not clearly documented.
3
Hepatorenal syndrome is AKI due to acute or chronic liver disease usually with ascites resistant to diuretics. It is diagnosed through exclusion of other causes and recognized as an MCC. Query as necessary.
4
If you suspect acute liver failure, consider querying for acuity of liver failure — acute liver failure is an MCC.
5
Review for indicators to support a query for coma related to hepatic failure or hepatitis. Indicators may include GCS < 8, abnormal EEG, and supportive documentation such as unconscious, stupor, or obtunded.

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