For hepatic encephalopathy without coma, report K76.82 plus a second code for the underlying liver disease. When the hepatic condition is documented with coma, report one “with hepatic coma” code instead, and leave out K76.82. Liver transplant complications go in T86.4-, and transplant status goes in Z94.4.
What is hepatic encephalopathy?
Hepatic encephalopathy is a neurologic complication of severe liver disease. When the liver can’t do its job, toxins it would normally break down and clear out build up in the blood and reach the brain. That disrupts brain function. The result can be anything from subtle shifts in mental status to confusion, disorientation, and coma.
It usually shows up in people with advanced liver disease or cirrhosis. Alcohol use, kidney disease, and infection are common triggers, since each can further impair the liver or increase the production or absorption of toxins.
For coders, the challenge is sorting out how the encephalopathy relates to the underlying liver disease, whether a coma is documented, and whether a liver transplant is involved. Get those three things right and the code assignment follows.
How do you code hepatic encephalopathy without coma?
The approach depends on whether the underlying hepatic condition is documented with or without coma. ICD-10-CM uses different code combinations for each, so the documentation decides everything. The goal is to capture the hepatic manifestation and, where appropriate, the underlying liver disease, while following the instructional notes in the Tabular List.
When hepatic encephalopathy is documented without coma, you generally report two codes:
- K76.82, hepatic encephalopathy
- An additional code for the underlying liver disease
The underlying condition might be alcoholic hepatic failure, toxic liver disease, acute or subacute hepatic failure, chronic hepatic failure, postprocedural hepatic failure, or certain forms of viral hepatitis. Depending on etiology and acuity, these codes may apply:
| Code | Description |
|---|---|
| B15.9 | Hepatitis A without hepatic coma |
| B16.1 | Acute hepatitis B with delta-agent without hepatic coma |
| B16.9 | Acute hepatitis B without delta-agent and without hepatic coma |
| B17.10 | Acute hepatitis C without hepatic coma |
| B19.10 | Unspecified viral hepatitis B without hepatic coma |
| B19.20 | Unspecified viral hepatitis C without hepatic coma |
| B19.9 | Unspecified viral hepatitis without hepatic coma |
| K70.40 | Alcoholic hepatic failure without coma |
| K71.10 | Toxic liver disease with hepatic necrosis, without coma |
| K72.00 | Acute and subacute hepatic failure without coma |
| K72.10 | Chronic hepatic failure without coma |
| K72.90 | Hepatic failure, unspecified without coma |
| K91.82 | Postprocedural hepatic failure |
Why two codes?
The two-code approach keeps the manifestation and the cause separate. K76.82 represents the encephalopathy. The second code tells the story of what kind of liver disease is behind it and why. Before you fall back on a nonspecific liver disease code, read the record for the underlying cause, the acuity, and any statement linking the encephalopathy to the liver disease.
How do you code hepatic coma?
When the underlying hepatic condition is documented with coma, you report a single “with hepatic coma” code for that condition. You don’t report two codes this time.
Examples for hepatic failure:
- K70.41, alcoholic hepatic failure with coma
- K72.01, acute and subacute hepatic failure with coma
- K72.11, chronic hepatic failure with coma
- K72.91, unspecified hepatic failure with coma
Viral hepatitis codes that may apply:
| Code | Description |
|---|---|
| B15.0 | Hepatitis A with hepatic coma |
| B16.0 | Acute hepatitis B with delta-agent with hepatic coma |
| B16.2 | Acute hepatitis B without delta-agent and with hepatic coma |
| B17.11 | Acute hepatitis C with hepatic coma |
| B19.0 | Unspecified viral hepatitis with hepatic coma |
| B19.11 | Unspecified viral hepatitis B with hepatic coma |
| B19.21 | Unspecified viral hepatitis C with hepatic coma |
Why isn’t K76.82 reported with a hepatic coma code?
ICD-10-CM treats hepatic coma codes as already including the encephalopathic manifestation. That’s a classification choice meant to stop the same clinical picture from being reported twice. The Tabular List backs this up with an Excludes1 note under K76.82 for the applicable hepatic coma codes.
This doesn’t mean hepatic encephalopathy can’t occur with coma clinically. It means the classification represents the condition differently once a coma is documented.
One more point: Glasgow coma scale codes should be reported as additional codes only alongside traumatic brain injury codes.
What should inpatient coders look for?
The key is deciding whether the record supports hepatic encephalopathy without coma or an underlying hepatic failure diagnosis with coma. A reduced level of consciousness or altered mental status is not, by itself, documentation of hepatic coma. The provider’s diagnostic statement has to support the “with hepatic coma” classification before you assign the code.
How do you code liver transplant complications and status?
Some patients with advanced or end-stage liver disease have already had a liver transplant. A transplant can restore liver function, but recipients still face complications that can affect the new organ and contribute to their current condition. So review the provider’s documentation to decide whether the transplant is simply history or is directly tied to what’s happening now.
Look for documentation that clearly states a problem is a complication of the liver transplant, and for the type of complication. Depending on the wording, these codes may apply:
| Code | Description |
|---|---|
| T86.40 | Unspecified complication of liver transplant |
| T86.41 | Liver transplant rejection |
| T86.42 | Liver transplant failure |
| T86.43 | Liver transplant infection |
| T86.49 | Other complications of liver transplant |
You may also need to report transplant status. Z94.4 (liver transplant status) shows the patient has had a liver transplant. It’s useful when the transplant is part of the ongoing clinical picture but no current complication is documented.
Coding example: toxic metabolic encephalopathy with hepatic encephalopathy
Take a patient with NASH cirrhosis and a history of hepatic encephalopathy. They present with altered mental status and are diagnosed with toxic metabolic encephalopathy (TME) secondary to acute-on-chronic hepatic encephalopathy.
Is TME inherent to hepatic encephalopathy?
No. According to AHA Coding Clinic, TME is not inherent to hepatic encephalopathy. When the provider documents TME in addition to hepatic encephalopathy, code the TME separately with G92.8 (other toxic encephalopathy). That way the codes reflect the diagnoses the provider actually documented, instead of assuming the toxic metabolic component is automatically included.
What about the underlying liver condition?
A “code first” note means an underlying condition may need to be reported before the manifestation code. Here, the provider documents acute-on-chronic hepatic encephalopathy but doesn’t specify the underlying hepatic failure. When hepatic encephalopathy is the only liver-related diagnosis and no cause is given, guidance points to K72.90 (hepatic failure, unspecified without coma), along with the appropriate encephalopathy code.
So the final code set reflects the acute-on-chronic hepatic encephalopathy and separately captures the TME. The lesson: read the whole record for the underlying liver disease and the specific cause of the encephalopathy before you finalize codes.
Frequently asked questions
Can you report K76.82 with a hepatic coma code? No. K76.82 has an Excludes1 note for the applicable hepatic coma codes, because those codes already include the encephalopathic manifestation.
How many codes do you report for hepatic encephalopathy without coma? Generally two: K76.82 and an additional code for the underlying liver disease.
Does altered mental status mean hepatic coma? No. A reduced level of consciousness or altered mental status alone doesn’t establish hepatic coma. The provider must document it.
Is toxic metabolic encephalopathy included in hepatic encephalopathy? No, per AHA Coding Clinic. Code TME separately with G92.8 when the provider documents it.
Which code do you use when only hepatic encephalopathy is documented and no cause is given? K72.90, hepatic failure, unspecified without coma, along with the appropriate encephalopathy code.
Which code shows a patient has had a liver transplant? Z94.4, liver transplant status. Use T86.4- codes only when a complication is documented.
References
- ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027 (CDC/NCHS, PDF)
- ICD-10-CM files and Tabular List downloads (CDC/NCHS)
- AHA Coding Clinic for ICD-10-CM/PCS, guidance on toxic metabolic encephalopathy and hepatic encephalopathy (add the issue and page number you are citing)
