ICD-10 Coding for Abnormal Lab Results(R79.9, R73.09)
Complete ICD-10-CM coding and documentation guide for Abnormal Lab Results. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Lab Results
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range covers codes for abnormal blood chemistry results that do not have a definitive 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 | Abnormal finding of blood chemistry, unspecified | Use when lab results show abnormal blood chemistry but no specific diagnosis is documented. |
|
| R73.09 | Other abnormal glucose | Use when glucose levels are abnormal but not linked to 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 Results
Primary ICD-10-CM Codes for lab result
Decision Criteria
clinical Criteria
- Abnormal blood chemistry without a specific diagnosis
Applicable To
- Abnormal blood chemistry
Excludes
- Abnormal glucose (R73.09)
Clinical Validation Requirements
- Lab results indicating abnormal blood chemistry without a specific diagnosis
Code-Specific Risks
- Overuse when a more specific code is available
Coding Notes
- Ensure no specific diagnosis is documented before using this code.
R73.09 - Other abnormal glucose
Use when glucose levels are abnormal but not linked to a diabetes diagnosis.
Applicable To
- Abnormal glucose levels
Excludes
- Diabetes mellitus (E08-E13)
Clinical Validation Requirements
- Glucose levels over 200 mg/dL with no diabetes diagnosis
Coding Notes
Ensure physician documentation does not indicate diabetes.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Lab Results 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 incorrect diagnosis coding, Regulatory: Non-compliance with coding guidelines, Financial: Potential for denied claims
Mitigation Strategy
Always require physician documentation, Verify lab results with clinical notes
Impact
Reimbursement: May lead to incorrect DRG assignment, Compliance: Non-compliance with specificity requirements, Data Quality: Decreased accuracy in clinical data
Mitigation Strategy
Use R73.09 for abnormal glucose levels.
Impact
Frequent use of unspecified codes like R79.9 can trigger audits.
Mitigation Strategy
Use specific codes whenever possible and ensure thorough documentation.
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 Results, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Lab Results
Use these documentation templates to ensure complete and accurate documentation for Abnormal Lab Results. These templates include all required elements for proper coding and billing.
Abnormal lab results without diagnosis
Specialty: Internal MedicineRequired Elements
- Lab test name
- Quantitative result
- Physician interpretation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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