Transaminitis is a medical term describing elevated liver enzymes found during routine blood work, signaling liver stress or injury. ICD-10 codes are the international classification system used by healthcare providers worldwide to document, bill, and track health conditions and procedures. These codes are required for processing insurance claims and for monitoring public health trends. Understanding how transaminitis is documented is important, as it functions differently from a confirmed disease diagnosis, translating medical findings into standardized alphanumeric codes.
Understanding Transaminitis
Transaminitis is not a disease itself but rather a sign that liver cells have been damaged, causing their contents to leak into the bloodstream. The two primary enzymes associated with this finding are Alanine Transaminase (ALT) and Aspartate Transaminase (AST). Both ALT and AST are normally contained within liver cells, where they help process amino acids, the building blocks of protein.
When liver cells are injured, their membranes become permeable, releasing these enzymes into the circulation. A significant elevation of these enzymes is a strong indicator of hepatocellular injury. Common causes include non-alcoholic fatty liver disease, medication side effects, excessive alcohol consumption, and viral hepatitis.
The ICD-10 Code for Abnormal Enzyme Levels
When a patient presents with only the laboratory finding of elevated transaminases without a definitive diagnosis for the cause, a specific code is used. The ICD-10-CM code that directly corresponds to this finding is R74.01, designated as “Elevation of levels of liver transaminase levels.” This code falls under the larger category of “Abnormal findings on examination of body fluids, substances, and tissues, without diagnosis.”
The R74.01 code is considered a symptom code, describing an abnormal lab result rather than an established disease. Healthcare providers use this specific code when the underlying cause for the enzyme elevation has not yet been determined. This signifies that elevated ALT and AST levels are the main finding while the patient is still being evaluated for the root problem.
Identifying and Coding the Underlying Condition
The fundamental guideline in ICD-10 coding requires that if a definitive diagnosis is known, the code for that disease must be listed first. Since R74.01 describes a symptom, it cannot typically be used as the primary or principal diagnosis when a related disease has been established. For instance, if the elevated transaminases are caused by non-alcoholic fatty liver disease (NAFLD), the code for NAFLD would be listed first.
The R74.01 code is then typically listed secondarily to provide additional detail, documenting the specific abnormal lab finding that led to the diagnosis. The ICD-10 system includes instructions, such as a “code first” note, that reinforce this sequencing rule. This practice ensures that billing and health statistics accurately reflect the true disease burden on the patient.
This coding structure directs the focus toward the etiology, or cause, which guides patient management. For example, if a patient has drug-induced liver injury, the code for the specific adverse effect of the medication would be the primary diagnosis, with R74.01 used as a secondary code. Using the underlying condition as the primary code is necessary for compliance and appropriate reimbursement.