ICD-10 Coding for Lab Review(R73.01, R82.5)
Complete ICD-10-CM coding and documentation guide for Lab Review. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lab Review
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range includes codes for abnormal lab findings that are not yet diagnosed as specific conditions.
Encounter for screening for other diseases and disorders
Used for preventive screenings and routine lab tests without specific symptoms.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R73.01 | Impaired fasting glucose | Use when fasting glucose levels are elevated but not diagnostic of diabetes. |
|
| R82.5 | Proteinuria | Use when proteinuria is detected without a specific 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 lab review
Essential facts and insights about Lab Review
Primary ICD-10-CM Codes for lab review
Decision Criteria
clinical Criteria
- Fasting glucose >125 mg/dL
documentation Criteria
- Physician's interpretation of lab results
Applicable To
- Fasting glucose level between 100 and 125 mg/dL
Excludes
- Diabetes mellitus (E08-E13)
Clinical Validation Requirements
- Fasting glucose >125 mg/dL
- HbA1c ≥6.5%
Code-Specific Risks
- Misclassification as diabetes without proper documentation.
Coding Notes
- Ensure fasting glucose levels are documented in the patient's record.
R82.5 - Proteinuria
Use when proteinuria is detected without a specific diagnosis.
Applicable To
- 24-hour urine protein >150 mg
Excludes
- Nephrotic syndrome (N04.-)
Clinical Validation Requirements
- Urine dipstick ≥2+
- 24-hour urine protein >150 mg
Coding Notes
Document specific protein levels and clinical correlation.
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 Lab Review to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R73.01.
Impact
Clinical: Misrepresentation of patient condition., Regulatory: Potential audit risk., Financial: Claim denials.
Mitigation Strategy
Verify the purpose of the visit, Ensure correct code selection
Impact
Reimbursement: May lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Query for documentation of clinical assessment.
Impact
Lack of documentation supporting lab tests.
Mitigation Strategy
Ensure all tests are linked to a clinical diagnosis.
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 Lab Review, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lab Review
Use these documentation templates to ensure complete and accurate documentation for Lab Review. These templates include all required elements for proper coding and billing.
Routine Lab Screening
Specialty: Primary CareRequired Elements
- Chief complaint
- History of present illness
- Lab test results
- Medical decision-making
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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