EmailDefinition of hepatitis C
Publication Date: December 2011
ICD 10 AM Edition: Seventh edition
Retired Date: 30/6/2017
Query Number: 2658
At our facility it is common to see the following qualifications in the documentation of Hepatitis C: ‘cleared’; with ‘SVR’ [sustained virological response]; ‘PCR –ve’; and ‘successfully treated’ with pegylated interferon and ribavirin. A review of the research literature indicates that some patients can be ‘cleared/cured’ of the Hepatitis C virus (HCV). This was confirmed in discussion with our Gastroenterologists.
A new treatment regime – a combination drug therapy of pegylated interferon and ribavirin – has proven itself effective in achieving a sustained virological response (SVR) across different genotypes of HCV. “The goal of treatment is to eradicate hepatitis C virus (HCV) RNA, which is predicted by the achievement of a ...SVR as defined by the absence of HCV RNA by polymerase chain reaction [PCR] six months after stopping treatment. An SVR is associated with a 99 percent chance of being HCV RNA negative during long-term follow-up.” A summary of evidence-based research on SVR and treatment outcomes support its use as a clinical indicator of viral eradication; in the words of the authors, “SVR is tantamount to cure.”
This new scenario creates a contradiction with the definition of Hepatitis C in ACS 0104 Viral hepatitis:
'Hepatitis C differs from hepatitis B in that a patient with hepatitis C will have the virus for the rest of their lives as either an acute or chronic infection or as an asymptomatic carrier'.
Based on this information, they cannot possibly be “cleared/cured” of the virus. It is clear that ACS 0104 needs to be reviewed, particularly the section on Hepatitis C and also the directives given via Coding Matters Volume 17, no. 1, June 2010 on 'Hepatitis C Cirrhosis'. A public submission to this effect is being prepared by this hospital for the NCCC.
As the concept of ‘cleared/cured’ Hepatitis C is not addressed in the ACS, and given the fact that viral hepatitis “should always be coded even if the criteria for additional diagnosis is not met.”, we have made some local coding decisions. We would like to submit these to the VICC for their comment:
• Potentially two situations with 'cleared' HCV infection:
(a) HCV 'cleared' – HCV-related liver disease still present
Example of Documentation seen: Cleared Hep C/ Hep C with SVR – HCV-related liver disease present [cirrhosis]
Code(s):
(1) HCV-related liver disease [e.g. cirrhosis K74.6]
(2) Sequelae of viral hepatitis B94.2
We have used the sequelae code given that the underlying condition (Hepatitis C) is now not present (per ACS 0008 Sequelae)
(b) HCV 'cleared' – HCV-related liver disease not present
Example of Documentation seen: Cleared Hep C/ Hep C with SVR
Code(s):
(1) Personal history of other infectious and parasitic disease Z86.18
As the notion of ‘cleared/cured’ Hep C is not addressed in ACS 0104 we have been coding this scenario to Z86.18. We make reference to the “Cured diabetes” section in ACS 0401 Diabetes Mellitus and Impaired Glucose Regulation (p. 110).
We acknowledge that the use of Z86.18 means taking ACS 2112 Personal History into account. It states to only assign a personal history code when the 'resolved' condition is directly relevant to the current episode of care. Does this mean Z86.18 would not be assigned when no sequelae condition is present and 'cleared' HCV is incidentally documented and is not the reason for admission.
Search Details:
ACS 0104 VIRAL HEPATITIS
ACS 0008 SEQUELAE
ACS 0401 DIABETES MELLITUS AND IMPAIRED GLUCOSE REGULATION [see 'Cured diabetes pg 110]
ACS 2112 PERSONAL HISTORY
Coding Matters Volume 17, Number 1, June 2010 on Hepatitis C Cirrhosis
Clinical Input: Director Gastroenterology, Alfred Health.
Chopra, S., (2011). Current treatment regimens for chronic hepatitis C virus infection. Retrieved 29 June, 2011 from UpToDate: http://www.uptodate.com/contents/peginterferon-and-ribavirin-for-the-treatment-of-chronic-
hepatitis-c-virus-infection-treatment-regimens?source=search_result&selectedTitle=7%7E150
Pearlman, B. L., & Traub, N. (2011). Sustained virologic response to antiviral therapy for chronic hepatitis c virus infection: A cure and so much more. Clinical Infectious Diseases. 52(7), 889-900. Retrieved 29 June 2011 from: http://cid.oxfordjournals.org/content/52/7/889.short?rss=1
A new treatment regime – a combination drug therapy of pegylated interferon and ribavirin – has proven itself effective in achieving a sustained virological response (SVR) across different genotypes of HCV. “The goal of treatment is to eradicate hepatitis C virus (HCV) RNA, which is predicted by the achievement of a ...SVR as defined by the absence of HCV RNA by polymerase chain reaction [PCR] six months after stopping treatment. An SVR is associated with a 99 percent chance of being HCV RNA negative during long-term follow-up.” A summary of evidence-based research on SVR and treatment outcomes support its use as a clinical indicator of viral eradication; in the words of the authors, “SVR is tantamount to cure.”
This new scenario creates a contradiction with the definition of Hepatitis C in ACS 0104 Viral hepatitis:
'Hepatitis C differs from hepatitis B in that a patient with hepatitis C will have the virus for the rest of their lives as either an acute or chronic infection or as an asymptomatic carrier'.
Based on this information, they cannot possibly be “cleared/cured” of the virus. It is clear that ACS 0104 needs to be reviewed, particularly the section on Hepatitis C and also the directives given via Coding Matters Volume 17, no. 1, June 2010 on 'Hepatitis C Cirrhosis'. A public submission to this effect is being prepared by this hospital for the NCCC.
As the concept of ‘cleared/cured’ Hepatitis C is not addressed in the ACS, and given the fact that viral hepatitis “should always be coded even if the criteria for additional diagnosis is not met.”, we have made some local coding decisions. We would like to submit these to the VICC for their comment:
• Potentially two situations with 'cleared' HCV infection:
(a) HCV 'cleared' – HCV-related liver disease still present
Example of Documentation seen: Cleared Hep C/ Hep C with SVR – HCV-related liver disease present [cirrhosis]
Code(s):
(1) HCV-related liver disease [e.g. cirrhosis K74.6]
(2) Sequelae of viral hepatitis B94.2
We have used the sequelae code given that the underlying condition (Hepatitis C) is now not present (per ACS 0008 Sequelae)
(b) HCV 'cleared' – HCV-related liver disease not present
Example of Documentation seen: Cleared Hep C/ Hep C with SVR
Code(s):
(1) Personal history of other infectious and parasitic disease Z86.18
As the notion of ‘cleared/cured’ Hep C is not addressed in ACS 0104 we have been coding this scenario to Z86.18. We make reference to the “Cured diabetes” section in ACS 0401 Diabetes Mellitus and Impaired Glucose Regulation (p. 110).
We acknowledge that the use of Z86.18 means taking ACS 2112 Personal History into account. It states to only assign a personal history code when the 'resolved' condition is directly relevant to the current episode of care. Does this mean Z86.18 would not be assigned when no sequelae condition is present and 'cleared' HCV is incidentally documented and is not the reason for admission.
Search Details:
ACS 0104 VIRAL HEPATITIS
ACS 0008 SEQUELAE
ACS 0401 DIABETES MELLITUS AND IMPAIRED GLUCOSE REGULATION [see 'Cured diabetes pg 110]
ACS 2112 PERSONAL HISTORY
Coding Matters Volume 17, Number 1, June 2010 on Hepatitis C Cirrhosis
Clinical Input: Director Gastroenterology, Alfred Health.
Chopra, S., (2011). Current treatment regimens for chronic hepatitis C virus infection. Retrieved 29 June, 2011 from UpToDate: http://www.uptodate.com/contents/peginterferon-and-ribavirin-for-the-treatment-of-chronic-
hepatitis-c-virus-infection-treatment-regimens?source=search_result&selectedTitle=7%7E150
Pearlman, B. L., & Traub, N. (2011). Sustained virologic response to antiviral therapy for chronic hepatitis c virus infection: A cure and so much more. Clinical Infectious Diseases. 52(7), 889-900. Retrieved 29 June 2011 from: http://cid.oxfordjournals.org/content/52/7/889.short?rss=1
Response
VICC acknowledges that clinical advances in this area means that ACS 0104 Viral hepatitis does not address the concept of cleared/cured hepatitis.
Upon review of the examples provided to illustrate the two scenarios noted in the query, we consider that it is appropriate to assign B94.2 Sequelae of viral hepatitis in cases of HCV 'cleared' – HCV-related liver disease still present and Z86.18 Personal history of other infectious and parasitic disease in cases of HCV 'cleared' – HCV-related liver disease not present.
VICC is aware that a public submission has been submitted to the NCCC to address the issues with ambiguious terms and defining symptoms (Reference number P118). Public submissions received by the NCCC can be viewed through the NCCC Information Portal (NIP) at:
http://nccc.uow.edu.au/productservices/nip/index.html
Upon review of the examples provided to illustrate the two scenarios noted in the query, we consider that it is appropriate to assign B94.2 Sequelae of viral hepatitis in cases of HCV 'cleared' – HCV-related liver disease still present and Z86.18 Personal history of other infectious and parasitic disease in cases of HCV 'cleared' – HCV-related liver disease not present.
VICC is aware that a public submission has been submitted to the NCCC to address the issues with ambiguious terms and defining symptoms (Reference number P118). Public submissions received by the NCCC can be viewed through the NCCC Information Portal (NIP) at:
http://nccc.uow.edu.au/productservices/nip/index.html
