ICD-10 Coding for Abnormal Laboratory Findings(R73.09, R79.1)
Complete ICD-10-CM coding and documentation guide for Abnormal Laboratory Findings. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Laboratory Findings
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range covers various abnormal blood test results that are not linked to a specific diagnosis.
Abnormal findings on examination of other body fluids, substances, and tissues, without diagnosis
This range includes abnormal findings in body fluids other than blood, such as urine or cerebrospinal fluid.
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 fasting glucose levels are elevated but diabetes is not diagnosed. |
|
| R79.1 | Abnormal levels of plasma proteins | Use for elevated plasma proteins indicating inflammation or infection. |
|
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
Essential facts and insights about Abnormal Laboratory Findings
Primary ICD-10-CM Codes for abnormal labs
Decision Criteria
clinical Criteria
- Fasting glucose ≥126 mg/dL with symptoms
documentation Criteria
- Documented repeat testing and symptoms
Applicable To
- Non-diabetic hyperglycemia
Excludes
- Diabetes mellitus (E08-E13)
Clinical Validation Requirements
- Fasting glucose ≥126 mg/dL on two occasions
- Symptoms of hyperglycemia such as polyuria or polydipsia
Code-Specific Risks
- Misclassification if diabetes is later confirmed
Coding Notes
- Ensure repeat testing and symptom documentation are present.
R79.1 - Abnormal levels of plasma proteins
Use for elevated plasma proteins indicating inflammation or infection.
Applicable To
- Elevated CRP
- Elevated ESR
Excludes
- Specific protein abnormalities (e.g., hypergammaglobulinemia)
Clinical Validation Requirements
- CRP >10 mg/L or ESR >30 mm/hr
- Associated symptoms such as joint pain or infection signs
Coding Notes
Link elevated protein levels to clinical symptoms for accurate coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Laboratory 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: May lead to incorrect diagnosis or treatment., Regulatory: Increases risk of non-compliance with coding guidelines., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Always document repeat tests when required, Ensure lab results are clearly linked to symptoms
Impact
Reimbursement: May lead to lower reimbursement rates due to lack of specificity., Compliance: Increases risk of audits and compliance issues., Data Quality: Reduces the accuracy of health data records.
Mitigation Strategy
Ensure documentation supports the use of specific codes like R73.09 instead of R73.9.
Impact
Increased audit risk when using unspecified codes without supporting documentation.
Mitigation Strategy
Use specific codes whenever possible and ensure documentation supports code selection.
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 Laboratory Findings, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Laboratory Findings
Use these documentation templates to ensure complete and accurate documentation for Abnormal Laboratory Findings. These templates include all required elements for proper coding and billing.
Endocrinology Progress Note
Specialty: EndocrinologyRequired Elements
- Lab Findings
- Interpretation
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Abnormal Laboratory Findings? Ask your questions below.