Recognizing The Symptoms: Coding NASH, The Silent Liver Disease

May 15, 2019

NASH – The Silent Liver Disease

Did you know that people can develop liver disease even if they do not drink alcohol?

A condition where fat accumulates in the liver is called nonalcoholic fatty liver disease (NAFLD).

Nonalcoholic steatohepatitis (NASH) is a type of NAFLD where the fat builds up in the liver and leads to inflammation and scarring (cirrhosis), which damages the liver and can become life-threatening.

NASH is called the silent liver disease because most people do not have or notice the signs or symptoms until they are in the more advanced stages. The more advance NASH becomes the more symptoms are noticed or develop. Sometimes the cause of NASH is never known.

 According to the American Liver Foundation, NASH is one of the leading causes of cirrhosis in adults in the United States – up to 25% of adults with NASH may have cirrhosis.

Years ago when a patient that did not use alcohol developed cirrhosis it was termed cryptogenic cirrhosis because the providers had no idea how the patient developed cirrhosis. Occasionally providers will still document it as cryptogenic cirrhosis when the cause has not been determined.

Who can develop NASH? Anyone can develop NASH. NASH is now the most common cause of liver disease in children who are obese. Yes, children are now being diagnosed with chronic liver disease which could lead to them needing a liver transplant.

Typically NASH is suspected when a provider orders routine blood work which returns with abdominal liver enzymes or an imaging test that shows a fatty liver. The only definitive way to accurately diagnosis NASH is doing a liver biopsy. The results will show if there is NASH and will also provide a grade and stage of the disease, inflammation (Grade 1 through 4) and bridging fibrosis (Stage 1 through 4). 

End stage liver disease is monitored regularly. The provider orders routine blood work and uses a Module For End Stage Liver Disease (MELD) Calculator to determine the patient’s MELD score. The MELD Score Range is 6-40 with 40 being severely ill.

SYMPTOMS (per Merck Manual):

  • Most patients do not have symptoms
  • Fatigue
  • Right upper quadrant abdominal discomfort
  • Hepatomegaly can develop
  • Splenomegaly may develop if advanced fibrosis is present
  • Patients who have cirrhosis due to NASH can be asymptomatic

RISK FACTORS (per Merck Manual):        

  • Diabetes
  • Obesity and/or metabolic syndrome
  • High cholesterol
  • High triglyceride levels
  • Hereditary
  • Certain medications

Non-alcoholic liver disease stages

  • Fatty Liver – Deposits of fat, liver can become enlarged
    • Liver Fibrosis – Scar tissue forms, cell injury
      • Cirrhosis – Liver becomes hard from scar tissue, liver unable to work properly


Until the disease progresses to end stage and requiring a liver transplant there really are not a lot of treatment options but there are somethings patients can do to manage their NASH. Below is a list of the common things that are recommended by providers. Each patient should go by the plan outlined by their own provider.

  • Weight loss
  • Exercise
  • Healthy Diet – Veggies, Fruits, Lean Protein or Plant Based Protein, Small Amount of Carbs (Best to see a Dietitian)
  • Avoid Alcohol Completely
  • See your provider regularly and stick with the program he or she outlines for you
  • Consistently high MELD score – liver transplant


Below are some of the ICD-10-CM Diagnosis codes that could potentially be assigned based on provider documentation.

  • Nonalcoholic steatohepatitis (NASH) – K75.81
  • Fatty liver, not elsewhere classified – K76.0
  • Other cirrhosis of liver – K74.69

The important thing to remember when assigning a code for steatohepatitis and/or cirrhosis is to not automatically assume it is alcohol related. It is important to read the record thoroughly and if in doubt query the provider for clarification of the type of steatohepatitis and/or cirrhosis.

Lorrie Strait, RHIT, CCS