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2025 ICD-10-CM code R80.9

Proteinuria, unspecified. Presence of abnormal levels of protein in the urine, without further specification.

This code should be used when documentation only indicates the presence of proteinuria, and specific information regarding the type or underlying cause isn't available. If a more specific code is applicable (e.g., R80.0 for albuminuria), it should be used instead. Code R80.9 should not be used if proteinuria is documented as a manifestation of another condition (e.g., preeclampsia, diabetes).

Medical necessity for further investigation depends on the context of the proteinuria. Persistent proteinuria often necessitates further evaluation to diagnose the cause and initiate appropriate treatment. Transient proteinuria, on the other hand, may not require extensive workup.

Clinicians are responsible for evaluating patients with proteinuria to identify the underlying causes, classify its type, and initiate appropriate treatment based on the severity of the condition.Further investigation may be required to distinguish between transient, orthostatic, or persistent proteinuria.

In simple words: This code indicates that tests found protein in your urine, but the exact type of protein or the reason for it isn't known yet.

Proteinuria, unspecified. This code signifies the presence of protein in urine, a deviation from the normal physiological state, where protein levels are typically minimal. The 'unspecified' designation indicates that the specific type of protein or underlying cause hasn't been identified or documented.

Example 1: A patient presents for a routine health checkup and a urinalysis reveals elevated protein levels. No other symptoms are reported, and further investigation is required., A patient with long-standing hypertension develops proteinuria, signaling potential kidney damage or nephropathy., A pregnant woman exhibits proteinuria during a prenatal visit, prompting further assessment for preeclampsia or other pregnancy-related complications.

Documentation should include the type of protein if identified (e.g., albumin, Bence Jones protein), method of detection (e.g., dipstick, 24-hour urine collection), quantitative amount of protein in the urine, and any associated signs or symptoms. Details of any underlying medical conditions (e.g., hypertension, diabetes) or medications that might contribute to proteinuria should be documented as well.

** Excludes1: gestational proteinuria (O12.1-). This code should be used as a placeholder until a more definitive diagnosis is made.

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