ICD-10 Coding for Heme Positive Stool(R19.5, K92.1)
Complete ICD-10-CM coding and documentation guide for Heme Positive Stool. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Heme Positive Stool
Other diseases of the digestive system
Includes conditions related to gastrointestinal bleeding.
R19.5Primary Range
Other fecal abnormalities
Used for abnormal findings in stool tests without visible blood.
Encounter for screening for malignant neoplasm of colon
Used for colorectal cancer screening scenarios.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R19.5 | Other fecal abnormalities | Use when a stool test is positive for blood but no visible blood is present. |
|
| K92.1 | Melena | Use when melena is present, indicating possible upper GI bleeding. |
|
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 heme positive stool
Essential facts and insights about Heme Positive Stool
Primary ICD-10-CM Codes for heme positive stool
Decision Criteria
clinical Criteria
- Positive stool test without visible blood
documentation Criteria
- Documented positive FOBT or FIT result
Applicable To
- Positive fecal occult blood test
- Positive FIT
Excludes
- Visible blood in stool
- Melena
Clinical Validation Requirements
- Positive FOBT or FIT result
- No visible blood in stool
Code-Specific Risks
- Should not be used as a primary code if visible blood is present.
Coding Notes
- Ensure documentation specifies the absence of visible blood.
K92.1 - Melena
Use when melena is present, indicating possible upper GI bleeding.
Applicable To
- Black, tarry stools
Excludes
- Bright red blood per rectum
Clinical Validation Requirements
- Black, tarry stools observed
- Upper GI bleed confirmed
Coding Notes
Ensure documentation specifies stool color and characteristics.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Heme Positive Stool to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R19.5.
Impact
Clinical: Leads to incorrect diagnosis coding., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Always specify test type and result, Include stool characteristics
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use K92.1 for melena cases.
Impact
Incorrect coding of screening as diagnostic can lead to audits.
Mitigation Strategy
Ensure clear documentation of screening intent.
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 Heme Positive Stool, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Heme Positive Stool
Use these documentation templates to ensure complete and accurate documentation for Heme Positive Stool. These templates include all required elements for proper coding and billing.
Routine screening with positive FIT
Specialty: GastroenterologyRequired Elements
- Patient demographics
- Screening intent
- Test results
- Follow-up plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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