ICD-10 Coding for Elevated ALT(R74.01)
Complete ICD-10-CM coding and documentation guide for Elevated ALT. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Elevated ALT
R74.0-R74.9Primary Range
Abnormal serum enzyme levels
This range includes codes for abnormal levels of liver enzymes, including ALT.
Key Information: ICD-10 code for elevated ALT
Essential facts and insights about Elevated ALT
Primary ICD-10-CM Code for elevated alternans
Decision Criteria
clinical Criteria
- ALT levels >3x ULN without definitive liver disease diagnosis
coding Criteria
- No confirmed diagnosis of hepatitis or liver disease
documentation Criteria
- Document specific enzyme and context (e.g., medication use)
Clinical Validation Requirements
- ALT levels above lab-specific reference range
- Documentation of specific enzyme and values
Code-Specific Risks
- Incorrect sequencing if a definitive diagnosis exists
- Potential audit if used as primary when not appropriate
Coding Notes
- Ensure ALT levels are documented with lab-specific reference ranges.
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 Elevated ALT 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 inappropriate treatment, Regulatory: Fails to meet documentation standards, Financial: Potential for denied claims
Mitigation Strategy
Always specify which enzyme is elevated, Include lab reference ranges
Impact
Reimbursement: Incorrect reimbursement due to misclassification, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Use the code for the definitive diagnosis as primary.
Impact
Using R74.01 as primary when a definitive diagnosis exists.
Mitigation Strategy
Review all diagnoses and ensure correct sequencing.
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 ALT, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated ALT
Use these documentation templates to ensure complete and accurate documentation for Elevated ALT. These templates include all required elements for proper coding and billing.
Elevated ALT in primary care
Specialty: Internal MedicineRequired Elements
- ALT value and reference range
- Duration of elevation
- Associated symptoms or lack thereof
- Relevant lifestyle factors
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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