ICD-10 Coding for Elevated Transaminase Level(R74.01)
Complete ICD-10-CM coding and documentation guide for Elevated Transaminase Level. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Elevated Transaminase Level
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range includes codes for abnormal blood chemistry findings, including elevated liver enzymes.
Key Information: ICD-10 code for elevated transaminase levels
Essential facts and insights about Elevated Transaminase Level
Primary ICD-10-CM Code for elevated transaminase level
Decision Criteria
clinical Criteria
- ALT/AST levels above normal without a known cause
coding Criteria
- No underlying condition identified
Clinical Validation Requirements
- Documented ALT and/or AST levels above the normal range
- Absence of a known underlying cause
Code-Specific Risks
- Using this code as a principal diagnosis when an underlying cause is identified
Coding Notes
- Ensure documentation specifies ALT/AST levels and any suspected etiology.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for screening for other viral diseases
Z11.59Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Elevated Transaminase Level to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R74.01.
Impact
Clinical: Lack of specificity can hinder diagnosis and treatment., Regulatory: May not meet documentation standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Always specify which liver enzymes are elevated., Include numerical values for ALT/AST.
Impact
Reimbursement: May lead to incorrect DRG assignment and reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code the underlying condition first, followed by R74.01.
Impact
Coding R74.01 without specifying ALT/AST levels can trigger audits.
Mitigation Strategy
Ensure documentation includes specific enzyme levels and any suspected etiology.
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 Transaminase Level, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated Transaminase Level
Use these documentation templates to ensure complete and accurate documentation for Elevated Transaminase Level. These templates include all required elements for proper coding and billing.
Patient with elevated liver enzymes and suspected drug-induced liver injury
Specialty: GastroenterologyRequired Elements
- Document ALT/AST levels
- Suspected cause (e.g., medication)
- Plan for follow-up testing
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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