ICD-10 Coding for Positive Fecal Immunochemical Test(R19.5)
Complete ICD-10-CM coding and documentation guide for Positive Fecal Immunochemical Test. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Positive Fecal Immunochemical Test
R19-R19.9Primary Range
Other symptoms and signs involving the digestive system and abdomen
This range includes codes for abnormal findings in fecal tests, including positive FIT results.
Key Information: ICD-10 code for positive FIT test
Essential facts and insights about Positive Fecal Immunochemical Test
Primary ICD-10-CM Code for positive fit test
Decision Criteria
clinical Criteria
- Positive result from a fecal immunochemical test
documentation Criteria
- FIT result documented in the patient's problem list
Applicable To
- Positive fecal immunochemical test
- Abnormal stool-based DNA test
Clinical Validation Requirements
- Documented positive FIT result
- Follow-up actions such as referral for colonoscopy
Code-Specific Risks
- Incorrectly using a screening code instead of R19.5
- Failing to document the FIT result in the problem list
Coding Notes
- R19.5 should be used as the primary diagnosis for follow-up colonoscopy after a positive FIT.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for screening for malignant neoplasm of colon
Z12.11Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Positive Fecal Immunochemical Test to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R19.5.
Impact
Clinical: May lead to missed follow-up and delayed diagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Implement checklist for documenting test results, Regular audits of patient records for completeness
Impact
Reimbursement: Incorrect coding can lead to denied claims or audits., Compliance: Using the wrong code can result in non-compliance with coding standards., Data Quality: Misclassification affects data accuracy and quality measures.
Mitigation Strategy
Always use R19.5 for positive FIT results to ensure proper follow-up and billing.
Impact
Using screening codes instead of R19.5 for positive results.
Mitigation Strategy
Educate staff on proper coding practices and conduct regular audits.
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 Positive Fecal Immunochemical Test, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Positive Fecal Immunochemical Test
Use these documentation templates to ensure complete and accurate documentation for Positive Fecal Immunochemical Test. These templates include all required elements for proper coding and billing.
Positive FIT result follow-up
Specialty: GastroenterologyRequired Elements
- FIT result and date
- ICD-10 code R19.5 assignment
- Colonoscopy referral
- Patient communication
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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