2025 ICD-10-CM code R75
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Laboratory - Abnormal findings on examination of blood, without diagnosis Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Inconclusive laboratory evidence of human immunodeficiency virus (HIV).
Medical necessity is established by the need to determine the patient's HIV status.Inconclusive test results necessitate further testing to ensure proper diagnosis and treatment, if necessary.The ordering physician should document the clinical rationale for testing and the reason for follow-up.
The clinical responsibility involves ordering and interpreting laboratory tests for HIV, counseling the patient about the inconclusive results, and ordering further testing as needed to clarify the diagnosis.The physician should communicate clearly with the patient about the need for additional testing and the implications of both a positive and negative HIV diagnosis.
- 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 a blood test for HIV was done, but the results are unclear.More tests are needed to find out if the person has HIV.
This code is used when laboratory testing for HIV is inconclusive, meaning the results are neither definitively positive nor negative for HIV infection.It applies to situations where further testing or investigation is needed to determine the patient's HIV status. This code should not be used if a definitive diagnosis of HIV infection (B20) or asymptomatic HIV infection (Z21) is established.
Example 1: A patient presents for routine blood work. The HIV antibody test is indeterminate. Code R75 is assigned pending further testing., An infant is tested for HIV as part of newborn screening. The results are inconclusive. Code R75 is assigned until further confirmatory testing is conducted., A patient with a history of risky behaviors undergoes HIV testing. Results are inconclusive due to interference or technical issues. Code R75 is utilized while retesting is performed to rule out a false negative or false positive reading.
Documentation should include the specific HIV test performed, the results, the reason for inconclusive results (if any), and any plans for further testing or follow-up care.The provider's note should clearly state that the test results are inconclusive and that a definitive diagnosis has not yet been established.
** It is crucial to follow up inconclusive HIV tests with confirmatory testing to avoid misdiagnosis and ensure appropriate management of the patient.
- Payment Status: Active
- Specialties:Infectious Disease, Internal Medicine, Family Medicine
- Place of Service:Office, Laboratory, Hospital