2025 ICD-10-CM code R78
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Laboratory Findings - Abnormal findings on examination of blood, without diagnosis Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified Feed
Presence of drugs or substances not typically found in the blood.
Medical necessity for this code is established by the clinical indication for the blood test. The presence of unexpected substances in the blood warrants further investigation to determine the cause, potential toxicity, and appropriate treatment.
The clinical responsibility for this code rests with the physician or healthcare professional who orders and interprets the blood test and who manages the patient's overall care.This includes ordering additional diagnostic tests, determining the cause of the abnormal finding, and initiating appropriate treatment.
- Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
- R70-R79: Abnormal findings on examination of blood, without diagnosis
In simple words: This code means that a blood test showed the presence of drugs or other substances that shouldn't be there.More tests are usually needed to find out why.
This code is used to report the finding of drugs or other substances in a blood test that are not normally present.It encompasses a broad range of substances and requires additional codes to specify the substance(s) identified.The presence of these substances may indicate various conditions, such as intoxication, poisoning, or illicit drug use. Further investigations are usually necessary to determine the cause and clinical significance of the finding.
Example 1: A patient presents to the emergency department after a suspected drug overdose. A toxicology screen reveals the presence of multiple illicit drugs in their blood. R78 is used to report the presence of these drugs, with additional codes used to specify each substance found., A routine pre-employment physical reveals the presence of an elevated level of a specific medication in the employee's blood sample. This finding is coded using R78, with additional codes added to identify the specific drug., A patient is admitted to the hospital with unexplained neurological symptoms.Blood tests reveal the presence of heavy metals, leading to a diagnosis of heavy metal poisoning. R78.7 is used, along with codes to specify the type of heavy metal and the clinical manifestations.
Complete laboratory reports specifying the substances identified, their concentrations, and the date and time of the test.Patient's history, symptoms, and physical examination findings should be documented.Any treatment provided should also be recorded.
** This code is for reporting the finding itself, not the underlying cause or condition. Additional codes should always be used to describe the specific substance(s) detected and any related diagnoses or conditions.
- Payment Status: Active
- Specialties:Toxicology, Emergency Medicine, Internal Medicine, Occupational Medicine
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Laboratory