2025 ICD-10-CM code R78.2
(Active) Effective 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 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Finding of cocaine in blood.
No modifiers are applicable to ICD-10-CM codes.
Medical necessity for testing for cocaine in the blood must be supported by the patient's clinical presentation or risk factors.The rationale for testing should be clearly documented in the medical record.
Clinicians should interpret this finding in the context of the patient's clinical presentation and history.Further investigation or consultation might be necessary to determine the clinical significance, particularly if there is no documented history of cocaine use.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R00-R99: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedR70-R79: Abnormal findings on examination of blood, without diagnosisR78: Findings of drugs and other substances, not normally found in bloodR78.2: Finding of cocaine in blood
In simple words: Cocaine has been found in the patient's blood test.
The presence of cocaine has been detected in the patient's blood, indicating recent use or exposure.
Example 1: A patient presents to the emergency department with altered mental status, tachycardia, and hypertension. A urine drug screen is positive for cocaine, and subsequent blood tests confirm the presence of cocaine, coded as R78.2., During a routine pre-employment health screening, an individual's blood work reveals the presence of cocaine.The individual denies cocaine use. Further investigation is conducted to rule out false-positive results or other underlying medical conditions., A patient undergoing a surgical procedure requires routine blood work. The results indicate the presence of cocaine. The anesthesiologist and surgeon are informed to adjust the anesthesia and surgical plan as needed, and a note is made of the incidental finding (R78.2).
Documentation should include the specific test performed (e.g., blood test), the result indicating the presence of cocaine, and the date and time the sample was collected.Additional documentation regarding the clinical context, such as relevant signs, symptoms, or history, should also be included.
** This code (R78.2) represents an abnormal laboratory finding and should be used in conjunction with other codes that fully describe the patient's condition and reason for the test.Consider using additional codes to describe any related conditions, such as cocaine dependence (F14.2-) or cocaine-induced mental disorders (F14.0-F14.1, F14.3-F14.5, F14.8-, F14.9-).
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