Fibrosis Score
Notes
**Note 1:** Physician statement of fibrosis score can be used to code this data item when no other information is available. However, code 7 when the physician statement of fibrosis score is not based on histologic examination of the liver.
**Note 2:** FIB-4 is NOT a pathological fibrosis score of 4. It is a scoring method using the patient's age and relevant lab values to calculate a score. The medical record may show something like "FIB-4 = 3.52." Do not code FIB-4 values in this data item.
**Note 3:** AJCC classifies Ishak fibrosis scores 0-4 (none to moderate fibrosis) as F0, and Ishak fibrosis scores 5-6 (cirrhosis/severe fibrosis) as F1. This is not the same as METAVIR score F0 or F1.
**Note 4:** Record the results based on information collected during the initial work-up through the first course surgery, in the absence of neoadjuvant treatment. If multiple histologic assessments of the liver (biopsies or resections) are taken and have conflicting scores, record the highest score.
* Information collected after the start of neoadjuvant treatment or primary systemic or radiation therapy may not be used to code this data item
**Note 5:** To use codes 0 and 1, you must have a histological (microscopic) confirmation of fibrosis/cirrhosis. Code the absence (code 0) or presence (code 1) of fibrosis as documented in the pathology report.
**Note 6:** Use code 7 if there is a clinical diagnosis (no microscopic confirmation) of severe fibrosis or cirrhosis.
**Note 7:** If no score is mentioned, descriptive terms may be used to assign codes 0 and 1 - see specific terms in the table below.
**Note 8:** If a fibrosis score is stated but the scoring system is not recorded, consult with the physician. If no further information is available, code 9.
Default
8
Metadata
SSDI
| Code |
Description |
| 0 |
Any of the following histologically confirmed
* No to moderate fibrosis
* Ishak fibrosis score 0-4
* METAVIR score F0-F3
* Batt-Ludwig score 0-3 |
| 1 |
Any of the following histologically confirmed
* Advanced/severe fibrosis
* Developing cirrhosis
* Incomplete cirrhosis
* Transition to cirrhosis
* Cirrhosis, probable or definite
* Cirrhosis, NOS
* Ishak fibrosis score 5-6
* METAVIR score F4
* Batt-Ludwig score 4 |
| 7 |
Clinical statement of advanced/severe fibrosis or cirrhosis, AND
Not histologically confirmed or unknown if histologically confirmed |
| 8 |
Not applicable: Information not collected for this case
(If this item is required by your standard setter, use of code 8 will result in an edit error.) |
| 9 |
Not documented in medical record
Stated in medical record that patient does not have advanced cirrhosis/advanced fibrosis, not histologically confirmed or unknown if histologically confirmed
Fibrosis score stated but cannot be assigned to codes 0 or 1
Fibrosis score stated but scoring system not recorded
Fibrosis Score not assessed or unknown if assessed |
