2025 ICD-10-CM code R78.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Abnormal findings on examination of blood, without diagnosis (R70-R79) Chapter XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Finding of opiate drug in blood.
The medical necessity for coding R78.1 is established by the presence of an abnormal laboratory finding (opiate presence in the blood) requiring further clinical investigation.The code is a temporary code used until a definitive diagnosis is established.The medical necessity for further investigation is based on the potential implications of opiate presence including toxicity, medication-related effects, or deliberate substance use.
The clinical responsibility involves ordering the blood test, interpreting the results, and performing further investigations to establish a diagnosis and determine appropriate treatment. This includes considering the possibility of accidental ingestion, illicit drug use, or medication-related effects.
- Chapter XVIII: 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: A blood test shows the presence of an opiate drug, but doctors need more information to figure out why it's there.
This ICD-10-CM code signifies the presence of an opiate drug detected in a blood examination, without a definitive diagnosis established.The finding requires further investigation to determine the underlying cause and clinical significance.
Example 1: A patient presents to the emergency department following an overdose. Blood tests reveal the presence of opiates.R78.1 is used as a preliminary code while further investigations, including toxicology screening and clinical assessment, are performed to determine the specific opioid and the context of its ingestion., A patient is involved in a motor vehicle accident. Blood tests are ordered as part of the routine workup. The presence of opiates is noted. R78.1 is assigned pending further evaluation to ascertain whether this is consistent with a prescription or indicative of substance abuse.Further investigation will involve review of the patient's medical history and the prescription medication list., During routine pre-operative blood work, a small amount of an opiate is detected. R78.1 would be used while investigating whether this is due to a prescribed opioid medication, recent exposure to an opiate, or another factor.
Complete blood test reports including the specific opiate detected and its concentration.Relevant patient history, including medication list, potential exposures, and any known history of opioid use or dependence.Detailed clinical notes summarizing the patient’s presentation, the reason for blood tests, and any other relevant findings. Toxicology reports, if applicable.
** This code is not for billing purposes; it serves as a placeholder until a more specific diagnosis is made.R78.1 should be used cautiously and replaced with a more specific code when the underlying cause is determined.
- Payment Status: Active
- Specialties:Emergency Medicine, Toxicology, Internal Medicine, Pain Management, Addiction Medicine
- Place of Service:Office, Hospital (Inpatient/Outpatient), Emergency Room, Laboratory