ICD-10 Coding for Abnormal Lab Result(R79.9, R73.09)
Complete ICD-10-CM coding and documentation guide for Abnormal Lab Result. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Lab Result
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range includes codes for various abnormal blood chemistry findings without a specific diagnosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R79.9 | Unspecified abnormal finding of blood chemistry | Use when no specific abnormality is documented. |
|
| R73.09 | Other abnormal glucose | Use for documented hyperglycemia without a diabetes 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 lab results
Essential facts and insights about Abnormal Lab Result
Primary ICD-10-CM Codes for abnormal lab result
Decision Criteria
documentation Criteria
- No specific abnormality documented
Applicable To
- Abnormal blood chemistry NOS
Excludes
- Specific abnormal findings with a confirmed diagnosis
Clinical Validation Requirements
- Documentation of abnormal blood chemistry without further specification
Code-Specific Risks
- Risk of under-coding if specific abnormality is known but not documented.
Coding Notes
- Ensure no specific abnormality is documented before using R79.9.
R73.09 - Other abnormal glucose
Use for documented hyperglycemia without a diabetes diagnosis.
Applicable To
- Non-diabetic hyperglycemia
Excludes
- Diabetes mellitus (E08-E13)
Clinical Validation Requirements
- Glucose level ≥140 mg/dL (fasting) or ≥200 mg/dL (random) without a diabetes diagnosis
Coding Notes
Ensure no diabetes diagnosis is present before using R73.09.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Lab Result to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R79.9.
Impact
Clinical: May lead to misinterpretation of patient condition., Regulatory: Non-compliance with documentation standards., Financial: Potential denial of claims due to lack of specificity.
Mitigation Strategy
Always document specific lab values and reference ranges.
Impact
Reimbursement: May lead to lower reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use the specific code for the documented abnormality.
Impact
Using unspecified codes when specific codes are available.
Mitigation Strategy
Ensure documentation supports the most specific code.
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 Result, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Lab Result
Use these documentation templates to ensure complete and accurate documentation for Abnormal Lab Result. These templates include all required elements for proper coding and billing.
Documenting abnormal glucose levels
Specialty: EndocrinologyRequired Elements
- Glucose level
- Reference range
- Absence of diabetes diagnosis
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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