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ICD-10 Coding for Abnormal Antinuclear Antibody(R76.0, R76.8)

Complete ICD-10-CM coding and documentation guide for Abnormal Antinuclear Antibody. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Positive ANAElevated ANA Titer

Related ICD-10 Code Ranges

Complete code families applicable to Abnormal Antinuclear Antibody

R76-R79Primary Range

Abnormal immunological findings in serum

This range includes codes for abnormal findings in immunological tests, including ANA.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
R76.0Raised antibody titerUse when ANA titer is elevated with a documented pattern, but no specific autoimmune disease is confirmed.
  • ANA titer ≥1:160 with specific pattern
R76.8Other specified abnormal immunological findingsUse when ANA pattern is specified but titer is not elevated.
  • ANA pattern specified without elevated titer

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for abnormal antinuclear antibody

Essential facts and insights about Abnormal Antinuclear Antibody

The ICD-10 code for an elevated antinuclear antibody titer with a documented pattern is R76.0. If the pattern is specified without an elevated titer, use R76.8.

Primary ICD-10-CM Codes for abnormal antinuclear antibody

Raised antibody titer
Billable Code

Decision Criteria

documentation Criteria

  • ANA titer and pattern must be documented.

Applicable To

  • Elevated ANA titer with documented pattern

Excludes

  • Specific autoimmune diseases (e.g., SLE, Sjögren’s)

Clinical Validation Requirements

  • ANA titer ≥1:160 with specific pattern

Code-Specific Risks

  • Using without specifying titer and pattern

Coding Notes

  • Ensure documentation includes both titer and pattern for accurate coding.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Systemic lupus erythematosus, unspecified

M32.9
Use as primary when SLE is confirmed.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Other specified abnormal immunological findings

R76.8
Use when ANA pattern is specified without elevated titer.

Raised antibody titer

R76.0
Use when ANA titer is elevated with a documented pattern.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Abnormal Antinuclear Antibody to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R76.0.

Impact

Clinical: Inadequate clinical information for diagnosis., Regulatory: Potential non-compliance with coding standards., Financial: Risk of claim denials.

Mitigation Strategy

Educate staff on documentation standards, Use templates for consistency

Impact

Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation.

Mitigation Strategy

Ensure documentation includes both titer and pattern.

Impact

Incomplete documentation of ANA titer and pattern.

Mitigation Strategy

Implement standardized documentation templates.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Abnormal Antinuclear Antibody, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Abnormal Antinuclear Antibody

Use these documentation templates to ensure complete and accurate documentation for Abnormal Antinuclear Antibody. These templates include all required elements for proper coding and billing.

Rheumatology Progress Note

Specialty: Rheumatology

Required Elements

  • Clinical history
  • Physical exam
  • Lab results
  • Assessment
  • Plan

Example Documentation

1. Clinical History: Fatigue, joint pain. 2. Physical Exam: Joint swelling. 3. Labs: ANA 1:320 speckled. 4. Assessment: Suspected Sjögren’s. 5. Plan: Further testing.

Examples: Poor vs. Good Documentation

Poor Documentation Example
ANA positive; monitor symptoms.
Good Documentation Example
ANA 1:320 speckled + anti-Ro/SSA. Diagnosed with Sjögren’s (M35.09). Code: M35.09, R76.0.
Explanation
The good example provides specific titer, pattern, and diagnosis, supporting accurate coding.

Need help with ICD-10 coding for Abnormal Antinuclear Antibody? Ask your questions below.

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