Understanding abnormal lab results, including abnormal laboratory findings and abnormal blood test results, is crucial for accurate clinical documentation and medical coding. This resource provides information on interpreting abnormal lab values, their implications for diagnosis and treatment, and best practices for healthcare professionals dealing with abnormal blood test results in a clinical setting. Learn about the importance of proper documentation of abnormal laboratory findings for effective patient care and accurate medical coding related to abnormal lab results.
Also known as
Abnormal findings on examination of blood
Abnormal blood test results indicating various conditions.
Abnormal findings on examination of urine
Abnormal urine test results, including chemical and microscopic findings.
Abnormal findings on examination of other body fluids
Abnormal findings in cerebrospinal fluid, stool, etc.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the abnormal lab result related to a specific diagnosis?
Yes
Is the diagnosis documented?
No
Is the abnormal finding isolated or part of a panel?
When to use each related code
| Description |
|---|
| Unusual lab values outside the normal range. |
| Elevated blood glucose levels. |
| Low blood potassium levels. |
Lack of specific lab test name and result leads to coding ambiguity and potential claim denials. Impacts CDI and medical necessity validation.
Missing documentation of the abnormal finding's clinical significance can cause downcoding and compliance issues. Affects physician query process.
Abnormal result without follow-up or confirmatory testing creates coding and billing inaccuracies, impacting revenue cycle management and healthcare compliance.
Q: What is the most effective approach to investigating abnormal liver function tests (LFTs) in asymptomatic patients?
A: Investigating abnormal liver function tests (LFTs) in asymptomatic patients requires a systematic approach. First, confirm the abnormality with repeat testing after excluding pre-analytical errors like improper sample handling. Then, assess the pattern of LFT abnormalities. A hepatocellular pattern (elevated AST and ALT) suggests hepatocyte injury, potentially from non-alcoholic fatty liver disease (NAFLD), viral hepatitis, or certain medications. A cholestatic pattern (elevated alkaline phosphatase and bilirubin) indicates biliary obstruction or dysfunction, possibly due to gallstones or primary biliary cholangitis. Further investigations may include viral hepatitis serologies, imaging studies (ultrasound, MRI), and potentially liver biopsy depending on the suspected etiology. Explore how specific LFT patterns can guide diagnostic workup and management decisions for asymptomatic patients. Consider implementing a standardized protocol for evaluating abnormal LFTs in your practice to ensure comprehensive and efficient patient care.
Q: How can I differentiate between benign and clinically significant abnormal blood test results in older adults considering age-related physiological changes?
A: Differentiating between benign and clinically significant abnormal blood test results in older adults can be challenging due to age-related physiological changes. Certain lab values, like creatinine, may be affected by decreased kidney function common in older adults, even without overt kidney disease. It's crucial to interpret results in the context of the patient's overall health, functional status, and medical history. For example, a slightly elevated creatinine in an otherwise healthy older adult might not warrant aggressive intervention, while the same result in a patient with multiple comorbidities could signify significant renal impairment. Consider age-specific reference ranges and trends over time rather than isolated values. Learn more about interpreting common laboratory abnormalities in the context of aging and explore strategies for personalized patient management based on individual risk factors and clinical presentation.
Patient presents today with abnormal lab results. Review of laboratory findings reveals [Specify abnormal lab value, e.g., elevated potassium level of 6.2 mEqL, decreased hemoglobin of 9.5 gdL, elevated white blood cell count of 15,000uL]. Differential diagnosis includes [List potential causes, e.g., dehydration, anemia, infection]. Patient reports [Patient-reported symptoms, e.g., fatigue, shortness of breath, fever]. Physical examination reveals [Relevant physical findings, e.g., pallor, tachycardia, abdominal tenderness]. Correlation of clinical presentation with abnormal laboratory data suggests [Working diagnosis, e.g., possible acute infection, iron deficiency anemia, hyperkalemia]. Plan includes [Further investigations, e.g., repeat blood work, urinalysis, imaging studies], [Treatment recommendations, e.g., IV fluids, iron supplementation, potassium binder], and patient education regarding the significance of the abnormal lab values and the importance of follow-up care. Medical coding considerations include [Relevant ICD-10 codes, e.g., R79.89 Other specified abnormal findings of blood chemistry, D64.9 Anemia, unspecified]. This abnormal laboratory result warrants further investigation to determine the underlying etiology and guide appropriate management. Follow-up appointment scheduled in [Timeframe, e.g., one week, two weeks] to review results of additional testing and assess response to treatment. Patient advised to contact the office if symptoms worsen or new symptoms develop.