2025 ICD-10-CM code R73.9
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Hyperglycemia Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Hyperglycemia, unspecified.This code indicates elevated blood glucose levels without a specified cause or diagnosis.
Medical necessity for assigning R73.9 is established when the patient presents with hyperglycemia and no other underlying diagnoses can be determined after appropriate investigation. The documentation must support the clinical findings of hyperglycemia and justify the selection of this unspecified code when more definitive causes cannot be identified.The medical necessity varies by payer and specific circumstances.
The clinical responsibility for coding R73.9 rests with the physician or qualified healthcare provider who conducts the initial assessment and performs the blood glucose testing.They should document their evaluation of the patient, including history, physical examination, laboratory results, and differential diagnoses considered.If no definitive diagnosis is reached, documentation should clearly explain why and indicate why R73.9 is being applied.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Abnormal findings on examination of blood, without diagnosis (R70-R79)
In simple words: This code means high blood sugar without a known reason. Doctors use it when they find high blood sugar but haven't figured out why yet.
R73.9, Hyperglycemia, unspecified, is an ICD-10-CM code used to classify instances of elevated blood glucose levels when the underlying cause or diagnosis is unknown or cannot be determined.It's applied when a more specific diagnosis related to diabetes mellitus, pregnancy complications, or other specified conditions cannot be established.This code should only be used when other relevant diagnostic possibilities have been explored and ruled out.
Example 1: A 65-year-old patient presents to the emergency room with symptoms of dizziness and weakness. Blood glucose levels are significantly elevated (300 mg/dL), but no other significant findings are noted.Further investigations, including a comprehensive metabolic panel and HbA1c testing, are planned but not completed before discharge. R73.9 is used., A 40-year-old female patient has a routine blood test that shows elevated glucose levels.No specific symptoms are reported by the patient.Further testing is recommended to rule out diabetes, but the patient does not return for follow-up.R73.9 is assigned., A 70-year-old male patient in a nursing home has a random glucose reading of 250 mg/dL as part of routine monitoring. No clear symptoms or history suggesting diabetes are present.More investigation is warranted, but the patient's condition precludes further intensive testing.R73.9 would be the appropriate code.
Comprehensive documentation is crucial for accurate coding.This should include the patient's presenting symptoms (if any), the results of the blood glucose test indicating hyperglycemia, and a detailed account of all relevant diagnostic procedures or tests performed to rule out other causes.The physician should document their reasoning for choosing R73.9 when no more specific diagnosis is possible.
** When a more specific diagnosis can be established following further investigation, the appropriate specific code should be used instead of R73.9.Always ensure the documentation supports the selected code.This code is used for temporary coding if other tests are needed to arrive at a final diagnosis.
- Payment Status: Active
- Specialties:Endocrinology, Internal Medicine, Family Medicine
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Emergency Room - Hospital, Skilled Nursing Facility