ICD-10 Coding for Lab Results Review(R79.9, R73.01)
Complete ICD-10-CM coding and documentation guide for Lab Results Review. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lab Results Review
R70-R79Primary Range
Abnormal findings on examination of blood, without diagnosis
This range includes codes for abnormal blood chemistry results that require further investigation or correlation with clinical findings.
Diabetes mellitus
Relevant when abnormal lab results are attributed to diabetes, requiring specific diabetes codes.
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 findings on examination of blood, unspecified | Use when lab results are abnormal but no specific diagnosis is confirmed. |
|
| R73.01 | Impaired fasting glucose | Use when fasting glucose levels are elevated and diabetes is confirmed. |
|
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 results review
Essential facts and insights about Lab Results Review
Primary ICD-10-CM Codes for lab results review
Decision Criteria
clinical Criteria
- Abnormal lab results without a specific diagnosis
Applicable To
- Abnormal blood chemistry NOS
Excludes
- Specific abnormal findings classified elsewhere
Clinical Validation Requirements
- Documented abnormal lab values without a clear diagnosis
- Physician's note indicating the need for further investigation
Code-Specific Risks
- Risk of overuse when specific conditions are not ruled out
Coding Notes
- Ensure documentation supports the use of R79.9 by indicating the need for further investigation.
R73.01 - Impaired fasting glucose
Use when fasting glucose levels are elevated and diabetes is confirmed.
Applicable To
- Elevated fasting glucose
Excludes
- Diabetes mellitus (E11-E13)
Clinical Validation Requirements
- Fasting glucose >126 mg/dL
- HbA1c ≥6.5%
Coding Notes
Ensure diabetes management is documented when using R73.01.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for general adult medical examination without abnormal findings
Z00.00Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Lab Results Review to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R79.9.
Impact
Clinical: Leads to unclear clinical picture., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Require exact values (e.g., 'Hgb 10.2 g/dL with MCV 72 fL'), Ensure clinical interpretation is documented
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Use R73.09 for transient hyperglycemia without a diabetes diagnosis.
Impact
Frequent use of unspecified codes like R79.9 without adequate documentation.
Mitigation Strategy
Ensure all abnormal findings are documented with specific lab values and clinical interpretation.
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 Results Review, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lab Results Review
Use these documentation templates to ensure complete and accurate documentation for Lab Results Review. These templates include all required elements for proper coding and billing.
Review of abnormal lab results
Specialty: Internal MedicineRequired Elements
- Test name and date
- Numeric result with reference range
- Clinical interpretation
- Action plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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