ICD-10 Coding for Elevated Transaminases(R74.01)
Complete ICD-10-CM coding and documentation guide for Elevated Transaminases. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Elevated Transaminases
R74.0-R74.9Primary Range
Abnormal serum enzyme levels
This range includes codes for elevated liver enzymes, specifically ALT and AST, which are critical for diagnosing liver conditions.
Key Information: ICD-10 code for elevated transaminases
Essential facts and insights about Elevated Transaminases
Primary ICD-10-CM Code for elevated transaminases
Decision Criteria
clinical Criteria
- Documented ALT/AST levels above normal range
coding Criteria
- Use R74.01 for lab-confirmed enzyme elevations
documentation Criteria
- Include specific enzyme values and potential causes
Applicable To
- Elevated ALT
- Elevated AST
Excludes
- Abnormal liver function studies (R94.5)
Clinical Validation Requirements
- Documented ALT/AST levels above normal range
- Specific values and temporal pattern
Code-Specific Risks
- Incorrectly using for imaging studies instead of lab tests
Coding Notes
- Ensure the underlying cause is documented and coded first.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fatty (change of) liver, not elsewhere classified
K76.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Elevated Transaminases to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R74.01.
Impact
Clinical: May lead to misdiagnosis or delayed treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Document specific enzyme levels and potential causes., Use templates to ensure comprehensive documentation.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on liver enzyme elevations.
Mitigation Strategy
Use R74.01 for enzyme elevations; R94.5 only for imaging/functional studies.
Impact
Using R94.5 instead of R74.01 for lab tests.
Mitigation Strategy
Educate staff on the correct use of codes for lab vs. imaging studies.
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 Transaminases, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated Transaminases
Use these documentation templates to ensure complete and accurate documentation for Elevated Transaminases. These templates include all required elements for proper coding and billing.
Elevated transaminases due to NAFLD
Specialty: GastroenterologyRequired Elements
- History of present illness
- Lab results
- Imaging findings
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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