Understand subtherapeutic INR, its implications, and proper documentation. Find information on managing subtherapeutic international normalized ratio, including clinical significance, diagnosis codes (ICD-10), monitoring, and treatment strategies. Learn about the importance of accurate healthcare documentation and medical coding for patients with subtherapeutic INR levels. Explore resources for clinicians and healthcare professionals related to subtherapeutic prothrombin time, anticoagulation management, and patient safety.
Also known as
Other coagulation defects
Covers abnormal clotting including subtherapeutic INR.
Poisoning by coumarin anticoagulants
Subtherapeutic INR may relate to improper coumarin use.
Other long-term drug therapy
Captures ongoing anticoagulant therapy and related complications.
Encounter for therapeutic drug monitoring
Includes checking INR levels and adjusting medication.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is INR subtherapeutic due to medication noncompliance?
Yes
Code Z91.128, Patient noncompliance with medication regimen
No
Is there a documented adverse effect causing low INR?
When to use each related code
| Description |
|---|
| Subtherapeutic INR |
| Elevated INR |
| Unstable INR |
Insufficient documentation of INR values and therapeutic range leading to coding errors and compliance issues.
Lack of clear documentation linking subtherapeutic INR to the underlying condition, impacting accurate code assignment and reimbursement.
Missing documentation of medication adjustments and patient education related to anticoagulant therapy, affecting quality reporting and audits.
Subtherapeutic International Normalized Ratio (INR) noted. Patient presents with [stable/unstable] vital signs and [asymptomatic/symptomatic] with complaints of [list specific symptoms, e.g., bleeding, bruising, epistaxis, or none]. Current INR value is [insert value] which is below the therapeutic target range of [insert target range]. Patient's medical history includes [list relevant medical history, e.g., atrial fibrillation, deep vein thrombosis, pulmonary embolism, mechanical heart valve, recent surgery] and is currently prescribed warfarin [dosage and frequency]. Medication adherence was reviewed with the patient. Possible causes for subtherapeutic INR were explored, including dietary changes, drug interactions with [list medications], and missed doses. Plan of care includes [adjusting warfarin dosage, e.g., increasing dose to, frequency to; ordering repeat INR in [number] days; patient education regarding warfarin therapy, dietary considerations, medication interactions, and importance of INR monitoring; close monitoring for signs and symptoms of thrombosis or bleeding]. Differential diagnosis includes [list relevant differentials, if applicable]. Assessment for potential bleeding risk factors was performed. Patient understands the importance of maintaining a therapeutic INR and agrees with the plan. ICD-10 code [insert appropriate code, e.g., Z79.01 for long term use of anticoagulants].