Don’t assume that cirrhosis is due to alcoholism unless specified.

ALWAYS document the underlying etiology of cirrhosis:

  • Viral (Hep B, C, or D)
  • Alcohol
  • Cryptogenic (NASH)
  • Autoimmune
  • Hemachromatosis

ALWAYS document associated conditions when present:

  • Ascites
  • Esophageal Varices (with or without bleeding)
  • Hepatic Encephalopathy
  • Jaundice
  • Portal Vain Thromobosis
  • Spontaneous Bacterial Peritonitis

Documentation Example: “Cirrhosis due to Hep C with ascites and non-bleeding esophageal varices”
*Remember – altered mental status or confusion does not mean encephalopathy. Be sure to document “hepatic encephalopathy” (MCC) and not just the signs/symptoms.

Download the complete tip, Cirrhosis.