ICD 10 Transaminitis: Choosing and Billing R74.01

R74.01 is the US ICD-10-CM code for transaminitis, which indicates elevated levels of ALT and/or AST. The description for this code is “Elevation of levels of liver transaminase levels.” It is typically assigned when the clinician has documented transaminitis, and the cause is still under evaluation.

From an administrative perspective, this is a complete and assignable diagnosis code. It would depend on the overall clinical documentation, the reason for the visit, and existing diagnoses, as to whether this code would be assigned on a particular claim.

A provider can quickly look up a diagnosis code, but that leaves other questions. For instance, what if the AST is normal, and the ALT is just elevated? What if there is fatty liver disease? Could this code be used to represent a liver panel? Why might a claim for a liver panel still be denied?

The following sections of this guide address those questions in the order they are likely to occur. Those questions are: determine the finding, assign a diagnosis code, review the note, and evaluate the services being billed. There are examples to illustrate coding decisions. They are hypothetical.

Transaminitis ICD-10 Codes at a Glance

Begin with actual abnormality. Numerous codes are found in searches for elevated liver enzymes; however, they describe different findings.

The descriptions in this table are shortened for readability.

A practical distinction: ALT and AST require the same answer for transaminase question. ALP and LDH require separate answer for code review. Although found on the same laboratory report, they are not interchangeable.

R74.01 versus R74.0

Code R74.0 consists of the more specific codes R74.01 and R74.02. Select the complete code, as appropriate, for a current claim.

R74.01 was developed and implemented on October 1, 2020. Old templates or diagnosis favorites may still map to R74.0. A code retained in an electronic health record can appear familiar long after it has ceased to be an appropriate code to select for a claim.

R74.01 versus R74.8

R74.01 describes an increase in transaminases. R74.8 describes other serum enzyme abnormalities that do not fall under any other codes and are reported with that code.

Consider alkaline phosphatase, isolated. This is also reported as transaminitis, as it is reported in a hepatic panel. If the clinician documents elevated alkaline phosphatase, follow it through the code-selection process.

R74.9, R94.5, and R79.89

The codes should not be used as defaults for an unclear note.

“Unspecified serum enzyme abnormality,” “abnormal liver function studies,” and “other specified abnormal blood chemistry” denote various categories. The words used in the assessment are important.

If the note only says, “abnormal LFTs,” it is important to find out what the clinician means, and it is not always the case that ALT or AST are the issues. If the existing record does not answer the question, clarifying what the clinician means is better than assuming the software suggests the first code and using it.

Where R89.0 fits

R89.0 is reported with abnormal levels of enzymes found in biopsied or removed specimens of other body organs, systems, and tissues.

It should not be assigned if the abnormality is in the blood and liver as the usual alternatives are elevated ALT and AST, respectively.

Evaluate the specimen as well as the enzyme. A match on the word “enzyme” alone should not determine the correct code.

What Transaminitis Tells You About the Patient

Transaminitis describes an observation. It does not explain the disease or exposure that caused the observation.

ALT, (alanine aminotransferase), and AST, (aspartate aminotransferase), are the enzymes most commonly involved.

ALT is more closely related to liver cell injury.

AST is found in the liver and other tissues, including skeletal muscle.

It is important to distinguish the difference between the two when AST is elevated and the liver is not definitely involved. The coder is unable to identify the cause of the elevation from the number alone.

Clinicians evaluate and integrate all of the data when interpreting the results of lab tests including the patient’s symptoms and other pertinent historical data, examination findings, other test results, and the rest of the laboratory panel. For ALT, a cause and concerns for follow-up for two patients may be different, although the ALT levels for the two patients may be the same.

Elevated enzymes do not cause liver failure

Many patients see the term “abnormal liver function” and immediately think their liver is failing. That is not the case with the codes as written.

Although the liver panel is used to evaluate the same patient over a period of time, not all items on the liver panel serve the same purpose. AST and ALT help to evaluate cell injury, while other items like total bilirubin and albumin serve different parts of the clinical picture.

Likewise, the presence of transaminases in the blood does not mean that the patient has cirrhosis or fatty liver disease.

One elevated transaminase can be enough

R74.01 includes elevated ALT and elevated AST. Both do not have to be abnormal.

If ALT is elevated but AST is normal, and the clinician evaluates the elevated ALT, R74.01 may still be appropriate. Consider if the elevated ALT is reportable for that encounter and look for an abnormal number, not two.

There is no separate code for mild transaminitis

R74.01 doesn’t change because of the description of elevation as mild, marked, acute, or persistent, by the clinician.

Those details are still important in a clinical context to justify the need for urgency or explain the type of tests ordered and the level of follow-up.

The code also does not define an absolute laboratory threshold. Flagging a laboratory result does not constitute that the laboratory system has made a diagnosis; the laboratory system may have printed the result in red, but that does not warrant that a diagnosis has been made. The result still requires clinical judgment.

How to Decide Whether R74.01 Belongs on the Claim

Read the assessment before choosing a diagnosis on the laboratory screen. A brief review of the complete visit usually addresses the questions that a code search cannot.

1. Identify what the clinician documented

Look for findings such as elevated ALT, AST, or transaminitis.

The wording doesn’t need to be exactly like the code description. When interpreting clinical terms and code titles, differences are bound to happen. The main thing is that the documentation supports the code and there is no contradiction in the record.

A statement such as “abnormal labs” may require further documentation, especially if there are multiple labs that are abnormal.

2. Establish whether a cause is known

Segregate what has been verified from the speculative.

“Elevated ALT, cause undetermined” is not the same as “Elevated ALT due to established liver disease.” A list of potential causes is not the final diagnosis.

When working in the outpatient setting, encode to the level of certainty that you are working with. Do not turn a suspected medication effect or a hepatitis work-up that is being done to evaluate a possible diagnosis into a confirmed diagnosis.

3. Check whether the finding is independently reportable

When a routine confirmed condition is the cause of the elevated enzymes, the abnormal finding is typically not reported separately, unless an instruction dictates it.

There are instances where a finding is reportably in addition to the basic finding. This is decided on a case-to-case basis, considering the documented relationship, the applicable instruction, and the setting.

Equally, discussing an integral finding in a different paragraph does not justify an additional code. Likewise, a blanket rule should not be applied that R74.01 will always disappear when a patient has any diagnosis relating to the liver.

4. Identify the reason for this encounter

There may be a patient who has transaminase elevations on their problem list that is not related to the current issue for which they are seeking care.

Review the work that was performed or ordered and the rationale for the service. The diagnosis list from the previous visit provides a starting point for review; however, it is not a final diagnosed list.

5. Verify the complete code

Check the term in the Alphabetic Index and verify the entry in the corresponding Tabular List. This will assist you in completing this final step in validation of the code.

This step is especially useful when a practice has carried the same set of diagnosis favorites through multiple annual updates. This may occur when a practice’s approach to care has not changed.

First-Listed Diagnosis: The Setting Changes the Answer

R74.01 can initially be listed for an outpatient visit to address a documented elevation of transaminases, as no other priorities exist for sequencing.

No. The same answer can’t be reproduced in all cases. A preventive exam, observation stay, inpatient admission, and diagnostic-only appointment require independent analysis.

Office and other outpatient visits

Assume a patient wishes to discuss an elevated ALT level at their next appointment. The clinician reviews the history and other pertinent information. Based on the information presented, there has been no established cause.

R74.01 could be an appropriate ICD-10-CM code describing the reason for that problem-oriented visit.

If the clinician documents “possible fatty liver” or “suspected drug effect,” these possibilities should not be coded as confirmed outpatient diagnoses. The record may support the documented enzyme finding and/or any other conditions present and addressed in the visit.

Emergency department and observation encounters

Just because a patient is treated in a hospital, it does not mean the patient is an inpatient.

Emergency and observation services are outpatient services. Consequently, diagnosis codes assigned based on services provided in these locations will generally be outpatient codes. Those distinctions are important for codes such as “probable hepatitis” or “rule out medication injury.”

Always verify the patient’s actual encounter status before relying on uncertainty rules. The location of the patient is just one of the factors to be evaluated.

Inpatient admissions

The process for selecting the principal diagnosis for inpatients is different from that for outpatients. For inpatients, the condition established after the study as being chiefly responsible for the admission is reported as the principal diagnosis. An established probable or suspected diagnosis documented at the time of discharge may be reported as established in the covered inpatient stays, and following the outpatient approach may result in reporting a different diagnosis as the principal one.

R74.01 may be reported as the principal diagnosis of an inpatient stay if, after completion of the evaluation, it is determined to be chiefly responsible for the admission, and no other diagnosis or rule of sequencing would override this determination.

An incidental elevation of an enzyme level in a study performed for another reason does not meet this criteria.

Diagnostic-only appointments

Consider different coding rules for an office visit to review diagnostic results versus a separate encounter limited to diagnostic services.

If the result of a diagnostic test is available during the diagnostic encounter, it can influence the documentation of the diagnostic impression. During a subsequent office visit, the provider may still be working to fully understand the result in the context of the patient’s overall condition.

It is important to recognize which encounter you are coding and review the available documentation to determine if a change in code is warranted.

Preventive examinations

A new abnormal finding discovered during a preventive examination will not automatically assign R74.01 to the entire service.

An examination or any separately reportable work must be reviewed according to their respective rules. Generally, the rules indicate that services should be reviewed based on the diagnosis, order, and the documentation. An abnormal test finding should not be used to determine the default sequencing rule.

Documentation That Makes the Coding Decision Easier

Useful documentation does not require a great deal of detail. Clinicians just want to make sure that notes include information regarding their interpretation.

The most helpful records connect three things: the finding, the meaning of the finding in the current clinical context, and the plan. When one of these elements is missing, a coder may be able to determine that the result is abnormal, but may be unable to understand what the patient was being evaluated for.

Name the abnormality

“Elevated ALT” is more specific than “abnormal bloodwork.” “Transaminitis, etiology under evaluation” says more than “liver issue.”

If simple findings can be stated with the language the clinician used, then there is no reason to state those with language that makes them sound more definite or more serious than they are.

If there are many abnormal lab results, state which one(s) influenced the visit. That helps the next clinician, coder, and anyone reviewing the claim.

Keep values and dates easy to find

Laboratory findings are reported using specific units. Collection dates are critical as values may have changed over time. Compared to previous results, the findings may be new, improving, persistent, or changing.

The date a value was collected is often as important as the number. Results may be entered into the record months after they were collected.

Renal functions tests (RFTs) are ordered when clinical findings support an acute kidney injury (AKI) and must be repeated until the clinical findings improve or the AKI resolves. RFTs are ordered and repeated on a schedule guided by clinical findings to support AKI.

Nurses need to work with other nurses and explain assessments to understand the rationale and follow the professional code of ethics.

Describe the level of certainty

A reader should be able to discern if the cause is established, suspected, or unknown.

For Example:

• “Elevated ALT; cause not yet established.”
• “Transaminase elevation under evaluation; medication effect considered.”
• “Enzyme elevation attributed to the documented liver condition.”

Know that these statements cannot be substituted for one another. Use the one that best describes the clinician’s conclusion.

Explain why the next step is being taken

Understanding an order requires assessment of its purpose.

For example, a clinician may be reviewing a trend, or investigating a possible cause of a symptom, or checking the effect of a treatment decision. Documenting that reasoning provides the context for the testing or follow-up.

The note should capture the actual plan. A generic note template should not promote the use of the same interval of testing, ultrasound order, referral, or other orders in every transaminitis case.

Include the history that influenced the decision

Things to be considered include the patient’s medication, supplement, and alcohol history; the patient’s reported symptoms; past liver diagnoses; and past test results.

Not all the patient’s history needs to be transcribed in the assessment. Include the details that brought about the clinical judgment. Leave the remaining record available where appropriate.

Nurses can provide the desired information through medication reconciliation, as well as through the collection of pertinent information from other service providers. The information collected by the nurses can confirm a nurse’s clinical judgment. However, that information does not permit the coder to give a diagnosis.

A simple documentation framework

Finding: Elevated ALT, AST, or both, with the relevant laboratory date and results identified.

Assessment: The clinician’s interpretation, including whether a cause is established or still being evaluated.

Context: The symptoms, exposures, previous results, or existing conditions that influenced the assessment.

Plan: The testing, monitoring, referral, treatment, or counseling actually selected, with follow-up arrangements.

Use this framework to organize information, not to create clinical facts. Remove fields that do not apply and avoid prechecked statements that suggest a review occurred when it did not.

When a clarification query helps

Take clarification into consideration when the note is different from the results, the diagnosis changes with no explanation, or a potential cause is documented as confirmed elsewhere.

A neutral question may be “Please provide the clinical importance of the elevated enzyme levels and was a cause determined for this visit?”

Provide the context and leave room for the clinician to tell you the finding is not important, unrelated or undetermined. A query should resolve uncertainty rather than push the record toward a preferred code.

Common Causes and the Coding Decisions They Raise

The reason for transaminase elevation needs to be determined as part of the clinical evaluation. It is coded as documented.

That distinction becomes important when a diagnosis seems likely as a result of common risk factors. For example, a patient can be obese and take a lot of medications and also report alcohol use and still not have those factors individually account for a cause of an elevated ALT.

Fatty liver disease, MASLD, and MASH

Clinical records may use outdated terminology to refer to conditions, including NAFLD, NASH, MASLD and MASH.

Code the condition documented and verify the appropriate ICD-10-CM code.

Steatosis is not the same as steatohepatitis. The presence of certain metabolic risk factors and/or elevated transaminases does not confer the presence of MASH. Similarly, the presence of one of these elements should not be used to assign MASH if the clinician has not made the diagnosis.

If there is ambiguity with respect to the terminology within the record, it should be clarified as opposed to changing the terminology to something more favorable to the coder.

Viral hepatitis

A hepatitis screening order, exposure history, abnormal test result, and documented infection are different circumstances.

The choice of disease code can vary based on the hepatitis virus, whether the infection is acute or chronic, and other defining features. Do not select a chronic hepatitis code just because a hepatitis screening order was made as part of the work-up.

Pend the outpatient assessment to determine a cause. In the interim, report supported findings and conditions at the appropriate certainty level.

Alcohol-associated liver disease

A drinking history in and of itself does not warrant a diagnosis of alcohol-associated liver disease. The clinical diagnosis and the relevant relationship should be documented.

Likewise, a person’s drinking behavior should not dictate the status of the liver disease. A person may stop drinking, but the effects of the established liver disease remain.

The remission status of alcohol use disorder should also be documented separately from the person’s alcohol consumption, as should the person’s alcohol consumption, liver disease, and alcohol use disorder. Review each question independently.

Medication-related enzyme elevation

Just because a patient takes a medication does not mean that medication caused any abnormal results. Many things must be taken into consideration such as the timing of the medication and other findings. Always evaluate alternative explanations.

When coding a documented adverse effect to a correctly taken medication, the resulting condition and the responsible drug are identified according to instructions. Poisoning is coded in a different manner.

Coding a drug effect is dependent on the manifestation. K71.6 is NOT a broad code to indicate every instance of a drug effect on the liver. The coder must find the documented condition and instructions to determine the appropriate code.

The seventh character is required to identify the treatment phase for many codes. Initial does not always indicate the first treatment or visit, and subsequent does not mean the second visit or treatment.

Pregnancy

Conditions affecting the liver that are specific to pregnancy require a pregnancy-specific code with additional codes assigned as instructed. Coding is dependent on the diagnosis, trimester, and relation to the pregnancy.

Elevated ALT or AST do not confirm HELLP syndrome, intrahepatic cholestasis, or other obstetric complications. Other clinical findings and documentation must be present to support the diagnoses.

When considering OB GYN Billing Services, the obstetric assessment must be reviewed prior to assignment of a pregnancy code, or determining the placement of R74.01 on the claim. An automatic first-listed placement of R74.01 or use of a broad pregnancy code is not appropriate. If the relation to pregnancy is unclear, consult the treating clinician to clarify prior to finalizing the code assignment.

Practical Examples: How the Same Code Can Fit Different Records

The following examples illustrate the reasoning behind code selection. They assume the described documentation is present and do not prescribe treatment.

Example 1: ALT is elevated, but AST is normal

A patient returns for an appointment regarding their ALT level, which was last reported at 86 U/L and is above the laboratory’s reference interval. AST level is normal. The clinician documents the ALT elevation, reviews previous results and plans further evaluation.

Coding decision: Documentation of ALT elevation and planned further evaluation supports the use of code R74.01. The normal AST level does not prevent assignment of this code.

If the main purpose of the outpatient visit was to evaluate the ALT elevation and no other rule is applicable, then this code may be sequenced first. The value in this example does not represent a universal threshold for coding.

Example 2: The abnormal enzyme is alkaline phosphatase

Elevated alkaline phosphatase level is reported in a laboratory panel, while the levels of ALT and AST are in normal ranges. Based on this information, a cause is not established by the clinician.

Coding decision: Based on the results of the liver panel, R74.01 should not be assigned because elevated alkaline phosphatase levels may be reported in other body system panels (e.g. bone, kidney, or liver panels). Assign R74.8 to report the elevated alkaline phosphatase level.

The coder should not make assumptions about the cause of elevated alkaline phosphatase level as being related to bone or bile duct obstruction.

Example 3: A diagnosis is established after the first visit

During the first visit, the clinician documents elevated transaminases for which no cause is found. During a subsequent visit, the cause of the elevated transaminases is found.

Coding decision: R74.01 may accurately describe the first visit. The second visit may be coded to describe the condition responsible for the transaminase elevation and the associated findings, if present.

The condition documented on the later visit does not mean the diagnosis documented at the first visit was incorrect. Review the first and subsequent visits using the documentation pertaining to each and the circumstances applicable to the visit.

Example 4: Medication injury remains only a possibility

An outpatient assessment states that a medication effect is one possible explanation for elevated transaminases. Evaluation is ongoing.

Coding decision: Do not convert that possibility into a confirmed case of toxic liver disease. Apply the outpatient certainty rule to the findings and conditions actually established.

If a drug-related diagnosis is later confirmed, assess the manifestation, substance, and circumstances before assigning the relevant code combination. Consider the treatment phase to determine the most appropriate code combination.

Example 5: The claim points to the wrong diagnosis

Both diagnoses are documented on the claim; however, the reason for the service in the claim points to transaminitis. The payment request is supported by the laboratory service, and the service is related to the knee condition.

Coding decision: Look at the order, assessments, and service-line pointer. If the service-line pointer is incorrect, correct the claim data via the payer’s process.

A new diagnosis may not be warranted. Clinical documentation may be adequate to support payment when the claim communicates the reason for the service is transaminitis.

Example 6: An old finding keeps appearing on new claims

A patient had elevated liver enzymes in a previous episode and the current note states that this finding is resolved. However, the electronic record continues to add R74.01 to every subsequent visit.

Coding decision: In the current encounter, determine if any follow-up or history coding is warranted and remove the issue from the problem list if it is no longer considered an active diagnosis.

Removing a diagnosis from today’s claim does not remove the documentation of that diagnosis from the patient’s previous record.

Billing Liver Tests and Office Visits With R74.01

The diagnosis code indicates what was discovered or what reason prompted the visit. Procedure codes indicate the services that were performed.

A correct diagnosis does not automatically indicate that the associated test was done, that the office can bill for the test, or that the payer would cover the test. Answers to these would require a separate review.

Common laboratory procedure codes

Select the procedure actually furnished. Not every test ordered for evaluation would warrant billing. Choose the one directly performed. (or choose the one that most approximates what was performed)

Avoid duplicating panel components

Upon completion of all components of a defined panel, report the panel. Performing the same included tests separately can result in the service being duplicated.

This is a good place to review laboratory interfaces. A system can import individual test codes even if a panel code is already present.

Same day repeat testing requires additional consideration. The repeat service, medical necessity, documentating the repeat test order, and any modifier must support the actual repeat testing that occurred. A modifier should not be added because a duplicate test line was rejected.

Distinguish an order from a billable service

An ultrasound may be ordered or the specimen may be sent to an outside lab. This, however, does not mean the practice performed the ultrasound or furnished the laboratory test.

Determining which entity provided the service and which may bill it is also different from reviewing the results.

Avoiding these types of errors is essential to prevent billing for a service that was not provided or that was provided by a different entity. This also assists in the prevention of claims that appropriately describe the diagnosis but fail to describe the work performed by the billing entity.

Choose the E/M level from the documented work

Support for an office visit level by R74.01 is not provided automatically.

For office/outpatient evaluation and management services, determine the level of support, if any, for medical decision making and the total qualifying time, if any, under the requirements of the code.

Two encounters with R74.01 may be very different and may require very different levels of service. One encounter may be a simple discussion of a lab result and may require very little service. Another encounter may be a more complicated assessment and may require more service. Each of these services may be reported with an appropriate service code.

Review modifier 25 before using it

Simply offering same-day lab work does not warrant the use of modifier 25.

Consider the other services provided, applicable edits, payer requirements, and if the work documented is beyond the usual work associated with the other services.

In situations where it has been determined that modifier 25 is justified, the E/M service is reported with modifier 25. It will not compensate for an unsupported or missing diagnosis or for the lack of documentation for the work being billed.

Coverage and Denials: Look Beyond the Diagnosis Code

Why R74.01 describes that an evaluation was needed because of a liver-related condition is accurate, but this code does not guarantee payment for associated services.

Payment is determined by a variety of factors, including the payer’s policy and term, the physician and the clinical circumstances, and the benefit plan terms. Frequency limits, authorization requirements, claim editing, and other factors can affect the adjudication of a claim even if the diagnosis code itself is valid.

Check the policy that applied when the service occurred

Ensure the policy is applicable to the payer, service, jurisdiction and date of service.

A previous policy can be easy to find and refer to even after it’s replaced or retired. A diagnosis list placed in a billing reference several years back may not accurately describe a current claim.

When you are reviewing and taking action based on a policy, state which version of the policy you are referring to. Doing so will make it easier for you to take the next follow-up action, as opposed to having to look through old notes to explain the previous actions taken.

Keep diagnosis pointers specific

A claim may consist of several accurate diagnoses and still link a given service to the wrong line.

When reviewing service lines for laboratory and imaging studies, check the condition that actually supports the service. Do not assign every diagnosis in the encounter to the procedures as a substitute for checking the connection.

In the case of a payer’s request for a liver function test, the service line pointer should have been part of the review. Only then should anyone be required to request a new diagnosis from the clinician.

Read the reason and remark information together

A denial code identifies an issue to investigate. It rarely establishes the complete explanation by itself.

These are examples, not a complete list, of the most common reasons for denying reimbursement for transaminitis.

CARC 16 in particular, should not be interpreted to mean the claim is missing levels of ALT or AST. This concerns claim submission errors or other types of documentation requests and should not be construed as a denial of request for claim attachment or additional documentation.

Match the response to the problem

An adjustment or correction to a claim may be made when submitted data were in error. An appeal or reconsideration may be made when disputing a payment or coverage determination. Follow the payer’s process for the issue at hand.

For a medical-necessity dispute, provide the reasoning for the documented finding and the supporting data to support the service and supply the claim with all pertinent records. Repeatedly submitting the same claim with no added documentation will not change the outcome.

Hepatitis and/or fatty liver disease and/or any other diagnosis that appears on a covered code list should not be added to the record. The patient’s diagnosis and the supporting documentation should continue to reflect the record.

Be careful with patient responsibility

A denial doesn’t automatically mean you can bill the patient for the entire charge. Review the payer’s benefit, the contract, the payer’s determination, and any applicable notices. Employ the appropriate process for revealing potential costs to patients if there is uncertainty before the service.

Patients are entitled to a clear account of what happened to them and not a vague assurance that their diagnosis should have ensured payment.

Keeping Follow-Up Coding Accurate

Further evaluation of Transaminitis can occur over several visits. There is no maximum time period after which R74.01 has to be removed simply because a certain number of weeks or visits has occurred.

The record should be current to support the use of the code. Findings may remain unresolved, require ongoing assessment, or be part of a larger ongoing assessment.

The important question is what is the clinician addressing currently?

Improving results

A lower enzyme level doesn’t necessarily mean the problem has been resolved. It could mean that the clinician is still evaluating the cause of the problem.

A trending number may mean different things to different people. Before assigning a disposition to the problem, ensure you know the reason the clinician determined the problem has been resolved.

If there’s a trend toward the reference range, document it and disposition the problem. 

Normalized results

If the note states that the abnormality has resolved, the next encounter should show that it has been resolved. Coding for follow-up may be appropriate, and coding for history may also be appropriate, depending on the situation.

There is not always a replacement code for a resolved episode. R74.01 should not be replaced with another code without assessing the reason for the patient’s return.

A newly confirmed cause

Update the coding to reflect the diagnosis once a record is established. Then determine if the transaminase value is part of the diagnosis being coded or if it is a separately reportable condition.

Maintain the original description of the clinical situation. An earlier encounter may have rightfully been coded to an abnormal condition, even if a later encounter revealed it was not abnormal.

Outside records and copied notes

Lab reports and assessments can be dated, or copied, and then returned to the caller to give the appearance of a “current” document.

Check the specimen date, the latest clinician assessment, and the reason for the service. An outside lab result can be relevant without describing a new episode, and a copied diagnosis can be maintained in the record despite the clinical situation having resolved.

What R74.01 Means on a Patient’s Bill

For patients, the most relevant information from R74.01 is elevated ALT/AST was documented with the service.

R74.01 tells very little and leaves a lot to be answered. For example, it doesn’t say what the cause of the elevated levels are, how significant the elevated levels are, and if the levels will go down or persist. Only a clinician can answer these questions.

You should ask your clinician:

• What ALT/AST was elevated?
• Is this a new finding or change from previous results?
• Has a cause been found?
• What will the next steps be?
• Are there things about my meds, supplements, or symptoms that we need to consider?

We understand the billing code caused stress and anxiety about your medication. Did the description say the medication was not safe? If the concern is financial, ask your practice what service was billed and what the decision was from the insurance company. Was the amount shown an adjustment, charge, or patient responsibility?

You may need to ask different people to get the answers you’re looking for. Your practice can help connect you to the right person.

A Short Review Before the Claim Leaves the Practice

Do a final check to make sure you hit the points where information can change between the note and the claim.

Check whether:

• The record indicates the transaminase finding being reported.
• The diagnosis code is complete and valid for the effective date.
• Any confirmed cause and associated finding rules have been considered.
• Both inpatient and outpatient uncertainty rules have been handled appropriately.
• The diagnosis order is plausible for the encounter.
• The procedures billed match the procedures performed.
• There is no duplication of components on the panel.
• There is a basis for the modifiers used.
• Diagnosis pointers connect each service to its true reason.
• An old or resolved finding has not been entered automatically.

For recurring problems, look over just a few affected claims to determine what the common cause is. If the problem is due to a default code, change the default. If the problem is due to a diagnosis pointer, check the mapping. If the reason for the finding is unclear, change the documentation to clarify.

A focused correction is more useful than asking the staff to write long documentation.

Frequently Asked Questions

What is the ICD-10-CM code for transaminitis?

R74.01 is the US ICD-10-CM code for elevated liver transaminases, including ALT, AST, or both. It commonly applies during evaluation of the finding before a cause is confirmed, provided it is reportable for the encounter.

Is R74.01 a billable code?

Yes. R74.01 is a complete diagnosis code that can be submitted when supported by the record. Billable status does not guarantee coverage for a particular laboratory test, imaging service, or visit.

Can R74.01 be the first-listed diagnosis?

Yes, for an outpatient encounter chiefly addressing the transaminase elevation when applicable sequencing rules permit. Inpatient principal diagnosis selection requires a separate review of the admission and findings established after study.

Can I use R74.01 for elevated ALT alone or mild transaminitis?

Yes. Both ALT and AST do not have to be elevated. There is also no separate R74.01 subcode for mild transaminitis. The clinician’s documentation and the encounter’s reporting requirements determine whether the finding should be coded.

Should R74.01 be reported with confirmed liver disease?

It depends on whether the finding is integral to the confirmed condition, whether an instruction requires additional coding, and whether it is otherwise independently reportable. Do not automatically add it merely because the enzyme result was discussed separately.

When should R74.01 be removed from the claim?

Reassess its use when a cause is established, the finding resolves, or it no longer meets the reporting requirements for the encounter. An old abnormal result or an unchanged problem-list entry is not enough by itself to justify continued use.