Find comprehensive Lab Review information for healthcare professionals. This resource covers clinical documentation improvement, medical coding guidelines, ICD-10 codes, CPT codes, and healthcare compliance related to diagnostic testing. Learn about accurate lab test interpretation, result documentation, and best practices for optimizing reimbursement in medical billing. Explore how AI is transforming lab data analysis and improving patient care through efficient diagnostic coding and documentation.
Also known as
Abnormal findings on examination
Covers nonspecific abnormal lab results without further diagnosis.
Abnormal findings, NEC
Includes other abnormal findings not classified elsewhere.
Ill-defined and unknown cause
Used when the reason for the lab review is unknown.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the lab review for abnormal findings?
Yes
Is there a documented diagnosis?
No
Routine screening?
When to use each related code
| Description |
|---|
| Lab Review |
| Abnormal Lab Value |
| Long Term Medication Use |
Lack of proper documentation to support diagnoses coded from lab results, leading to inaccurate claims and potential denials. Medical coding, CDI, healthcare compliance.
Using unspecified codes when more specific diagnoses are available based on lab data, impacting reimbursement and data accuracy. Medical coding, CDI, healthcare compliance.
Overlooking additional diagnoses indicated by lab findings, affecting risk adjustment and accurate reflection of patient complexity. Medical coding, CDI, healthcare compliance.
Lab Review: Patient presented for review of recent laboratory results. Comprehensive metabolic panel revealed normal glucose, electrolytes, and renal function. Lipid panel demonstrated elevated low-density lipoprotein cholesterol (LDL-C), prompting discussion regarding lifestyle modifications including diet, exercise, and weight management. Complete blood count (CBC) showed normal white blood cell count, hemoglobin, and hematocrit, ruling out anemia and infection. Thyroid stimulating hormone (TSH) was within normal limits, excluding thyroid dysfunction. Liver function tests (LFTs) including alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were normal, indicating no evidence of liver disease. Urinalysis was unremarkable. Based on the lab review, the patient's elevated LDL cholesterol is the primary concern. Patient education provided regarding cardiovascular disease risk factors and the importance of cholesterol management. Discussed therapeutic options including statin therapy. Patient will follow up in three months for repeat lipid panel and further evaluation. Medical coding and billing will reflect evaluation and management services for lab review and counseling on hyperlipidemia.