ICD-10 Coding for Elevated Lactate(R74.02, E87.2)
Complete ICD-10-CM coding and documentation guide for Elevated Lactate. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Elevated Lactate
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R74.02 | Elevated lactic acid level | Use when lactate is elevated but does not meet criteria for acidosis or shock. |
|
| E87.2 | Acidosis | Use when lactic acidosis is present, not part of septic shock. |
|
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 elevated lactate
Essential facts and insights about Elevated Lactate
Primary ICD-10-CM Codes for elevated lactate
Decision Criteria
clinical Criteria
- Lactate >2 mmol/L without acidosis
Applicable To
- Hyperlactatemia without acidosis
Excludes
- Lactic acidosis (E87.2)
Clinical Validation Requirements
- Lactate level >2 mmol/L without acidosis or shock
Code-Specific Risks
- Misclassification if acidosis is present
Coding Notes
- Ensure documentation specifies absence of acidosis.
E87.2 - Acidosis
Use when lactic acidosis is present, not part of septic shock.
Applicable To
- Lactic acidosis
Excludes
- Septic shock (R65.21)
Clinical Validation Requirements
- Lactate >5 mmol/L with pH <7.35
Coding Notes
Do not use with R65.21 due to Excludes1 note.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Elevated Lactate to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R74.02.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims.
Mitigation Strategy
Always include clinical context., Specify if acidosis or shock is present.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Violates Excludes1 note., Data Quality: Impacts clinical data accuracy.
Mitigation Strategy
Use R65.21 alone for septic shock.
Impact
Coding E87.2 with septic shock can trigger audits.
Mitigation Strategy
Review Excludes1 notes and ensure correct 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 Elevated Lactate, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated Lactate
Use these documentation templates to ensure complete and accurate documentation for Elevated Lactate. These templates include all required elements for proper coding and billing.
Sepsis with elevated lactate
Specialty: Emergency MedicineRequired Elements
- Lactate levels
- Clinical context
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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