E78.1 Terminology and Clinical Context

Hypertriglyceridemia is characterized by high levels of triglycerides in the blood. Hyperlipidemia describes abnormal elevation of blood lipids. Dyslipidemia describes abnormalities in blood lipid levels, and may include low levels of HDL-cholesterol. Hyperlipidemia and Dyslipidemia describe a variety of lipid abnormalities, and do not permit the coder to substitute a preferred diagnostic term for the provider’s diagnosis.

The title of the code, E78.1, uses hyperglyceridemia. Clinicians may use hypertriglyceridemia. The Index also directs familial hypertriglyceridemia to E78.1. A semantic difference in the assessment versus the code title does not, by itself, make the code selection inappropriate.

The term ‘pure hypertriglyceridemia code’ is a misunderstanding. Hypertriglyceridemia is characterized by elevated levels of triglycerides in the blood. Hyperglycemia describes elevated levels of blood glucose. If these two terms are documented together, consult the provider or the real record for clarification.

Not all patients with hypertriglyceridemia will have symptoms. The presence of other conditions along with the overall pattern of lipids helps to determine the overall clinical concern, and may warrant further testing. Most patients without symptoms of cardiovascular disease do not have evidence of pancreatitis. Code selection cannot determine if a patient has cardiovascular disease or pancreatitis.

Choose the Code from the Documented Disorder

Isolated triglyceride elevation and mixed hyperlipidemia

An example is a diagnosis of “hypertriglyceridemia” on a clinic note, and an entry on the imported problem list of “mixed hyperlipidemia.” The task at hand is to reconcile the difference. Selecting the more specific of the two options may actually perpetuate the error.

Three conditions requiring separate treatment

Familial hypertriglyceridemia is recorded as E78.1, Familial combined hyperlipidemia is in E78.49, and Familial chylomicronemia is in E78.3, the pathway for hyperchylomicronemia.

A family history of high cholesterol or triglycerides raises the level of concern for further evaluation, but does not establish an inherited condition on its own. The assessment should capture the condition of the patient. This differentiates a condition that is potentially genetic dyslipidemia, from a more generalized condition documented by the treatment team.

“Mixed” needs its complete clinical term

“Mixed hyperlipidemia” and “mixed hypertriglyceridemia” sound the same, but their Index paths differ, E78.2 and E78.3, respectively. Read the whole phrase and do not rely on the word “mixed” to code it.

E78.5 can document the visit

A documented diagnosis of hyperlipidemia, without specifying the subtype, would support the use of E78.5. In the absence of specific information, it is acceptable to use an unspecified code. The use of E78.5 is not restricted to temporary codes.

Triglyceride Levels, Fasting Status, and Severe Disease

Clinical thresholds help explain a clinician’s assessment. They are not a substitute for that assessment.

These are clinical reference ranges. Automatic code-selection rules are not defined for lipid disorder codes. Elevated triglycerides may be due to a number of causes, such as familial chylomicronemia, pancreatitis, mixed hyperlipidemia, and others.

E78.1 should still be reported to identify severe hypertriglyceridemia, even in the absence of other specific lipid disorders, when the provider documents the condition. If the clinician documents hyperchylomicronemia, the coding pathway should be followed for hyperchylomicronemia. Medical Coding Services should follow the documented diagnosis and not rely on laboratory threshold interpretations.

Fasting status may be documented in the supporting record and should be considered by the clinician when determining additional work-up and testing. Coders should report code E78.1 in the absence of fasting, a normal cholesterol level, genetic testing, or proof that all secondary causes of hyperlipidemia have been ruled out.

Pancreatitis due to excessively elevated triglycerides is considered a medical emergency and patients should be treated accordingly.

Inclusion Terms, Exclusions, and Complete Codes

Elevated fasting triglycerides, endogenous hyperlipidemia, Fredrickson type IV, and VLDL type hyperlipoproteinemia are found in the Tabular List under E78.1. These terms assist in connecting the classification to the language used in clinical documentation.

Examples at the code, category, and chapter levels are:

• E78: An Excludes1 note mentions sphingolipidosis, E75.0-E75.3.
• E78.2: Excludes1 notes mention cerebrotendinous cholesterosis, E75.5 and familial combined hyperlipidemia, E78.49.

Excludes1 notes generally do not allow reporting of the excluded condition in conjunction with that code. There is a recognized exception for conditions that are clearly unrelated; clarification should be requested when the relationship is unclear. Notes should be applied to conditions documented rather than to conditions assumed.

Code completeness should be evaluated separately. E78.4 requires either E78.41 or E78.49. E78.0 has subcodes as well. Familial hypercholesterolemia, E78.01, requires E78.010, E78.011, or E78.019, for example. Not all general categories found in a competitor’s table are appropriate for claim submission.

Use the latest, official code files. Verification of the classification should be performed before a proposal to change the code is acted upon.

Documentation Supporting a Defensible Claim

The provider of the service documents the diagnosis. The coding staff translates the diagnosis to the classification. There are instances of discordance, often requiring clarification. When assignment of the diagnosis is unclear, the Coding Clinic directs coders to query the discordant documentation, based upon the provider’s diagnostic statement.

A useful record shows the provider assessed the service in question. Review these elements:

• Diagnostic statements: Hypertriglyceridemia, mixed hyperlipidemia, hyperchylomicronemia, or another established diagnosis.
• Findings: Relevant triglyceride and cholesterol fractions, if available, including unit and fasting status.
• Interpretation: Provider interpretation of the lipid pattern.
• Conditions: Relevant pertinent conditions such as diabetes, thyroid disease, kidney disease.
• Related: Whether the clinician relates the lipid disorder to another condition or to medication.
• Management: Provides medication, assessment, counseling, testing, rationale, referral, or other care.
• Consistency: If there is agreement between assessment and orders.
• Assessment: Hypertriglyceridemia. Fasting triglycerides 340 mg/dL. Consider medication tolerance and nutrition concerns. Ordered lipid panel to assess treatment response.

The provider described the lipid disorder, indicating that it was hypertriglyceridemia in this case. This supports a coding review aide for this documentation versus “lipids, abnormal” and supports the order of the lipid panel. The panel may have been ordered to assist in medication management and to assess treatment response versus the service level, which was documented.

A more neutral query may state:

“The assessment is hyperlipidemia, and the lipid panel is elevated. Please clarify what lipid disorder is being assessed, if determinable, or indicate that it is unspecified.”

The query requests clarification of what lipid disorder is being assessed, if determinable, or indicates that it is unspecified. The query does not provide a diagnosis and, therefore, does not link the clinician to a specific condition. The documentation supports the request. It may not require supporting documentation.

Make the source of each diagnosis visible

An EHR can document a problem as an imported entry, an abnormal lab result, and a signed clinical assessment, in the same chart. Each serves a different purpose. The lab interface can flag a result outside the reference range, and nursing staff can enter relevant data, including the patient’s concerns. The responsible provider must confirm and document the lipid diagnosis that is the basis of the coding.

Assessments that differ from a problem listed on the problem list should both be documented, and remain visible during review. One entry should not replace the other, without adequate justification. The record should document the condition being assessed and/or managed, to assist the Coding and Medical Billing Services team to reconcile the documented condition with the condition for which the practice is being paid, in accordance with the practice’s policies.

This principle is also applicable to a test ordered to an outside laboratory. The reason for the test, and not a diagnosis merely to satisfy an insurance edit, should be stated on the order. If the order is incomplete, the laboratory should request clarification, and should not assign a lipid diagnosis.

Hypertriglyceridemia, Diabetes

Diabetes and the lipid disorder

Diabetes and hypertriglyceridemia can occur together. Just because both are present on a problem list does not mean diabetes complications are present. Determine the documented relationship to the Index.

When a case of type 2 diabetes is complicated by hypertriglyceridemia, E11.69 can be used in addition to E78.1 to identify the complication. E11.69 explains to use an additional code to specify the complication. A review of an unlinked diagnosis pair should be conducted differently from a documented diabetic lipid complication.

Consider other diabetic complications for which additional combination codes may be required. Build the claim from the full assessment instead of applying one fixed pair to every patient with diabetes and abnormal lipids.

Secondary causes and medication effects

Conditions such as diabetes and thyroid disease as well as alcohol use and obesity may be considered. Relevance is at the clinical discretion of the patient.

Abnormal lipid results do not confirm obesity, alcohol misuse or drug adverse effects. Document conditions as appropriate, considering the specific situation and context in which the documentation occurs. If a clinician links a condition to a drug, assess the adverse effect or drug poisoning instructions, as applicable, rather than speculating a drug code.

There is not a universal rule for “underlying condition first” for secondary hyperlipidemias. Follow the rules and reason for the encounter.

Hypertriglyceridemia-associated pancreatitis

A documented diagnosis of pancreatitis is required. Coders may not assume pancreatitis in the presence of elevated triglyceride levels and/or abdominal pain.

When a clinician diagnoses acute pancreatitis as being caused by hypertriglyceridemia, there must also be a necrotizing or infectious process, and the code should be assigned as K85.80, Other acute pancreatitis, without necrosis or infection. The lipid disorder should also be documented and reported.

If there is a triglyceride focus of the clinical care, E78.1 should not be the principal diagnosis for all cases of pancreatitis.

Practical Coding Examples

These cases are for illustrative purposes only, and are not audited examples of Resilient MBS client engagements. Each example assumes the provided documentation is clinically supported and reportable.

Case 1: Assessment Documents Hypertriglyceridemia

A clinician documents hypertriglyceridemia and discusses a triglyceride level of 320 mg/dL and evaluates treatment. The relevant lipid diagnosis is E78.1. The coder does not need to replace the assessment with a potential familial or mixed disorder.

Case 2: Both Lipid Fractions are Elevated

The documentation states mixed hyperlipidemia, supported by elevated levels of both cholesterol and triglycerides. The documented diagnosis is E78.2. Adding E78.1 to restate the triglyceride component of the mixed hyperlipidemia is needless redundancy.

Case 3: The Familial Wording Changes the Pathway

A specialist documents familial combined hyperlipidemia. The correct classification is E78.49. Choosing E78.2, because the results contain both elevated cholesterol and triglycerides, disregards the more specific documented condition and its exclusion note.

Case 4: A Very High Result Does not Establish Subtype

There is a documented triglyceride level of 1200 mg/dL with an assessment of severe hypertriglyceridemia. E78.1 is the correct pathway, unless the clinician documents another classified disorder. The high level, alone, does not support changing the assessment to a familial chylomicronemia.

Case 5: Outpatient Diagnosis is Uncertain

Outpatient assessment indicates “possible hypertriglyceridemia” without confirmation. Apply outpatient uncertainty guidance, and report the reason, symptom, or abnormal finding as appropriate. Outpatient rules apply in the emergency department and observation. Qualifying hospital inpatient discharge settings can permit coding of uncertain diagnoses as established; apply that setting’s guidance.

For a patient reading these examples, a code on a portal is a classification of the documented condition. It does not explain the full risk assessment or treatment plan. The clinician can clarify the diagnosis for the patient.

Lipid Testing, Screening, and Procedure Billing

Diagnosis codes reflect conditions or reasons for services, and CPT codes reflect the procedures and/or tests performed. E78.1 is a diagnosis code and is not a procedure code. CPT 80061 is a laboratory test code for a lipid panel that consists of total cholesterol, HDL cholesterol, and triglycerides. CPT 84478 is the code for a test for triglycerides. In general, a panel code takes precedence over reporting the individual components of the panel. Code component codes only when reporting rules support that the component was performed as a separately distinct service.

A panel order should not be reported as an isolated test, simply because there is a relevant diagnosis on a payer’s coverage list. Likewise, a test that was not performed should not be reported simply because it was ordered or requested. Laboratory Medical Billing Services teams should review the order, test results, CPT code, and diagnosis before a claim is transmitted.

Screening and diagnostic testing

The rules for screening for lipoid disorders are described in Z13.220. Diagnostic testing rules evaluate the procedures associated with established triglyceride disorders. According to Medicare’s cardiovascular screening benefit, a Z13.6 code is the example provided for screening testing. Therefore, general screening codes should not be placed on every Medicare claim.

Lipid testing indications and limitations are described in CMS NCD 190.23. Benefits and testing indications for the commercial and Medicaid populations vary by the individual plan. It is recommended that you verify coverage and benefit policy, the testing indication, as well as applicable utilization rules prior to rendering testing and assuming E78.1 is an approved code.

E/M Services and Modifier 25

Choose an E/M office-visit code based on the documented requirements of the E/M service. A diagnosis of a lipid disorder does not in-and-of-itself determine the level of E/M service.

A lipid panel ordered on an E/M visit does not require modifier 25. Modifier 25 should only be used when there is a significant, separately identifiable E/M service, and it is supported by documentation, Coding Edits, and Payer requirements. CMS describes modifier 25 in that manner; it is not to be used in conjunction with every office visit that includes a laboratory test.

Resolve Denials Without Distorting the Diagnosis

A denied lipid claim requires a more detailed explanation. The phrase “diagnosis problem” can describe an invalid code, an inadequate code, an incorrect diagnosis pointer, or inadequate/missing supporting evidence.

Use a short exception workflow:

• Identify the affected service line, denial code, and payer explanation.
• Ensure the submitted diagnosis and procedure are consistent with the record.
• Verify code and/or diagnosis completeness, and appropriate edits.
• Consider the policy governing the service and benefit.
• Resolve inconsistent/inadequate documentation with a provider query.
• Appeal or correct the claim with supporting evidence and record the cause.
• improve the exception workflow.

An example is when a documented E78.1 is on the claim but the diagnosis pointer for the triglyceride test is missing. This is a linkage issue. If a service is excluded from benefit coverage, this is not resolved by automatically replacing E78.5 with a more specific diagnosis. Evidence and/or documentation supporting a performance claim should describe the defined population and exclusions, and be adequately measured. Codes, accuracy and completeness, can support a claim, but cannot make an excluded benefit payable, or denote medical necessity.

When appealing a decision, specifically identify the component(s) of the decision that are in dispute. Are you appealing the Testing Indication? Was there a Diagnosis Pointer error? Is it the applied policy? Is it some other documented adjudication issue? Provide the order and the assessment when it is requested. If you just request reconsideration, it may not give the payer a reviewable issue. A statement such as “the test was necessary” doesn’t address what was the reason for the denial.

How Resilient MBS Supports Accurate Lipid-Disorder Billing

Resilient MBS can assist clients with coding and billing for services related to the management of patients with hypertriglyceridemia and other associated metabolic conditions. The agreed upon scope may include reviewing and validating client documentation and counseling the client about coding issues.

A request for reconsideration should describe the component of the denied service that is in dispute, what code was assigned to that service, and what the affected service is. An exception statement that describes a “mixed/familial” terminology issue provides the client with a concrete issue to resolve. A statement such as “use a better code” does not.

It is the responsibility of the health care provider to establish the diagnosis and validate that diagnosis. The coding staff’s responsibility is to assign the correct codes based on the diagnosis and validate the diagnosis. The staff’s responsibility is to determine the coverage and submission requirements for the claim and resolve any issues with the claim.

Reporting and reviewing associated codes helps ensure the claim reflects the correct coverage and submission requirements.