ICD-10 Coding for Abnormal Lab Findings(R73.09, R79.1, R74.0)
Complete ICD-10-CM coding and documentation guide for Abnormal Lab Findings. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Lab Findings
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range includes codes for abnormal blood test results that do not have a definitive diagnosis.
Factors influencing health status and contact with health services
Includes codes for routine health examinations with abnormal findings.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R73.09 | Other abnormal glucose | Use when elevated glucose levels are noted without a confirmed diagnosis of diabetes. |
|
| R79.1 | Abnormal levels of plasma proteins | Use when elevated plasma proteins are noted without a definitive diagnosis. |
|
| R74.0 | Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH] | Use when elevated liver enzymes are noted without a definitive diagnosis. |
|
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 glucose levels
Essential facts and insights about Abnormal Lab Findings
Primary ICD-10-CM Codes for abnormal lab findings
Decision Criteria
clinical Criteria
- Fasting glucose ≥126 mg/dL without diabetes symptoms
Applicable To
- Persistent hyperglycemia without diabetes
Excludes
- Diabetes mellitus (E08-E13)
Clinical Validation Requirements
- Fasting glucose ≥126 mg/dL on two or more occasions
Code-Specific Risks
- Misclassification if diabetes is later confirmed
Coding Notes
- Ensure documentation specifies glucose levels and absence of diabetes diagnosis.
R79.1 - Abnormal levels of plasma proteins
Use when elevated plasma proteins are noted without a definitive diagnosis.
Applicable To
- Elevated C-reactive protein (CRP)
Excludes
- Autoimmune disorders (M35.9)
Clinical Validation Requirements
- CRP >10 mg/L with supporting clinical context
Coding Notes
Ensure documentation includes specific protein levels and clinical interpretation.
R74.0 - Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]
Use when elevated liver enzymes are noted without a definitive diagnosis.
Applicable To
- Elevated liver function tests (LFTs)
Excludes
- Hepatitis (B18.2)
Clinical Validation Requirements
- ALT/AST >3x upper limit of normal
Coding Notes
Ensure documentation specifies enzyme levels and absence of liver disease diagnosis.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Lab Findings to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R73.09.
Impact
Clinical: Misrepresentation of patient's diabetic status., Regulatory: Potential audit failure., Financial: Incorrect billing leading to claim denials.
Mitigation Strategy
Verify diabetes status before coding., Use E11.9 if diabetes is confirmed.
Impact
Reimbursement: Claims may be denied if unsupported by signed documentation., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation in patient records.
Mitigation Strategy
Ensure provider attestation and clinical significance are documented.
Impact
Coding without physician documentation increases audit risk.
Mitigation Strategy
Ensure all lab findings are documented with clinical significance.
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 Lab Findings, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Lab Findings
Use these documentation templates to ensure complete and accurate documentation for Abnormal Lab Findings. These templates include all required elements for proper coding and billing.
Primary Care Visit with Abnormal Lab Findings
Specialty: Primary CareRequired Elements
- Test Name
- Value and Normal Range
- Methodology
- Clinical Interpretation
- Provider Signature/Date
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Abnormal Lab Findings? Ask your questions below.