Abnormal Liver Tests: Clinical Approach, ICD-10 Coding, and Smarter Documentation

Abnormal liver tests, often flagged in routine lab panels, can be a perplexing yet critical finding for clinicians. Whether they reflect benign transient changes or signal underlying liver disease, elevated liver function tests (LFTs) demand thoughtful interpretation, documentation, and follow-up.

In this guide, we’ll walk you through:

• What qualifies as an abnormal liver test

• Common causes and diagnostic approach

• ICD-10 coding for elevated LFTs and related conditions

• Clinical documentation strategies

• How DocScrib can streamline liver-related documentation workflows

What Are Liver Function Tests (LFTs)?

A standard liver panel typically includes:

⚠️ ALT and AST are the most commonly elevated and often drive further workup.

What Constitutes an Abnormal Liver Test?

• ALT/AST >40 IU/L (varies slightly by lab)

• ALP >120 IU/L

• Total bilirubin >1.2 mg/dL

• Low albumin (<3.5 g/dL)

• INR >1.2 (without anticoagulation)

The significance depends on the pattern—whether hepatocellular, cholestatic, or mixed.

Common Causes of Abnormal Liver Tests

When to Investigate Abnormal Liver Tests Further

While some elevations are transient or benign, persistently abnormal LFTs or significant elevation (>2–3x upper limit) merit further evaluation:

• History & Physical Exam

• Repeat LFTs in 1–2 weeks

• Hepatitis panel (A, B, C)

• Ultrasound or CT scan

• Autoimmune or metabolic screening

• Liver biopsy (if diagnosis unclear)

ICD-10 Coding for Abnormal Liver Tests

Primary ICD-10 Code

✅ Use R94.5 for initial elevated ALT/AST when no underlying diagnosis is yet confirmed.

Additional ICD-10 Codes (Based on Underlying Cause)

Sample Clinical Documentation

Subjective:
“Patient seen for annual physical. No specific complaints. Routine labs revealed ALT of 82 and AST of 65. No alcohol use. No known liver disease.”

Objective:
Vitals stable. BMI 32. Abdomen soft, non-tender, no hepatomegaly. No jaundice or asterixis.

Assessment:
Elevated liver enzymes likely secondary to suspected NAFLD. No symptoms.
ICD-10: R94.5, K76.0

Plan:

• Order liver ultrasound and hepatitis panel

• Counsel on weight loss and dietary changes

• Recheck LFTs in 6 weeks

Documentation Tips for Abnormal Liver Tests

• State the abnormal labs clearly (include values and dates)

• Include likely cause if suspected (e.g., NAFLD, medication)

• Document if labs are persistently elevated or transient

• Always include next steps: imaging, labs, lifestyle counseling

• Pair R94.5 with other codes (e.g., K76.0, Z79.899) for specificity

Common Documentation Pitfalls

🚫 Using vague terms like “mildly abnormal labs” without specifics
🚫 Not linking abnormal LFTs to potential etiology
🚫 Forgetting to update from R94.5 to specific diagnosis when known
🚫 Omitting medications (e.g., statins, isoniazid) that could explain elevation

How DocScrib Improves Liver-Related Documentation

When it comes to abnormal labs like elevated liver enzymes, time-sensitive documentation and accurate coding are essential. That’s where DocScrib helps.

DocScrib Supports You By:

✅ Recognizing and flagging abnormal ALT/AST/GGT/Bilirubin in patient encounters
✅ Autogenerating problem lists with ICD-10 codes like R94.5 and K76.0
✅ Inserting lab values into SOAP notes automatically
✅ Recommending appropriate follow-up intervals and plans
✅ Saving providers hours in note writing—especially in primary care and internal medicine

Turn lab results into actionable, billable, and documented care—fast.
👉 Book your free DocScrib demo now

Quick ICD-10 Cheat Sheet: Abnormal Liver Test Scenarios

FAQs

Q1: When should I use R94.5 instead of a liver disease code?
Use R94.5 when abnormal LFTs are noted, but no definitive liver diagnosis has been established yet. Update the code when etiology is confirmed.

Q2: Can I use R94.5 with other codes?
Yes. It’s often paired with Z79.899 (medication use) or K76.0 (fatty liver) depending on context.

Q3: Is mild elevation clinically relevant?
Yes—especially if persistent or if patient has risk factors (e.g., obesity, alcohol use, metabolic syndrome).

Q4: Can DocScrib automate lab interpretation into my notes?
Yes. DocScrib detects abnormal labs, pulls them into your SOAP, and even suggests next steps based on AI-driven clinical logic.

Final Thoughts

Abnormal liver tests are common but not always benign. Identifying whether they reflect a reversible condition, an underlying chronic liver disease, or a medication side effect is key. Just as important is how you document and code these findings in the EHR.

DocScrib makes it easier than ever—turning lab values into structured, smart documentation that supports both clinical decision-making and billing.

👉 Book your free demo now and take your liver care documentation to the next level.