Don’t assume that cirrhosis is due to alcoholism unless specified.
ALWAYS document the underlying etiology of cirrhosis:
- Viral (Hep B, C, or D)
- Cryptogenic (NASH)
ALWAYS document associated conditions when present:
- Esophageal Varices (with or without bleeding)
- Hepatic Encephalopathy
- 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.