2025 ICD-10-CM code R78.0
Finding of alcohol in blood.Use additional external cause code (Y90.-) for details on alcohol level.
No modifiers are typically applicable to this code.
Medical necessity for this code is established by the presence of a positive blood alcohol test, regardless of the underlying cause or clinical context. This requires clinical correlation with the patient's presentation and history.
The clinical responsibility for this code involves obtaining and interpreting the blood alcohol test results, determining if further investigations are necessary to clarify the cause, and potentially providing appropriate clinical management based on the context of the finding.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R70-R79 (Abnormal findings on examination of blood, without diagnosis)
In simple words: This code means that alcohol was found in a blood test, but doctors don't know why or what the cause is.
This code signifies the presence of alcohol in the blood without a further specified diagnosis.Additional coding may be necessary to specify the level of alcohol detected and any related external causes.This code is used when the presence of alcohol is noted, but no other specific diagnosis can be made following investigation.
Example 1: A patient presents to the emergency department after a motor vehicle accident. A blood alcohol test reveals the presence of alcohol, but no other injuries are detected. R78.0 is used to document the finding of alcohol in the blood., A patient is brought into the hospital unconscious, and blood tests are conducted. The results show a high blood alcohol content. The code R78.0 is used in this case., During a routine physical examination, a patient's blood alcohol level is incidentally found to be elevated. Additional investigations are conducted to determine the cause, but none are found. The code R78.0 would be assigned to document the elevated blood alcohol level in the absence of a specific diagnosis.
Documentation should include the blood alcohol concentration (BAC) level, the method used to obtain the sample, the time of sample collection, and any relevant clinical findings.If additional tests or procedures were conducted to investigate the cause, these should be documented as well.
** This code should only be used when no specific diagnosis can be identified despite investigation. The clinical documentation should clearly support the use of this code, and appropriate external cause codes should be utilized if circumstances warrant.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Emergency Medicine, Toxicology, Internal Medicine
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital