2025 ICD-10-CM code R79.1
Abnormal coagulation profile. This includes abnormal or prolonged bleeding time, coagulation time, partial thromboplastin time (PTT), or prothrombin time (PT), and low von Willebrand factor.
Medical necessity for using R79.1 is established when an abnormal coagulation profile is identified through laboratory testing. This can be necessary for diagnostic purposes, to monitor anticoagulant therapy, assess bleeding risk before procedures, or investigate symptoms suggestive of a bleeding disorder.
Clinicians ordering and interpreting coagulation tests, such as physicians, nurse practitioners, or physician assistants, are responsible for using this code when documenting abnormal findings.Laboratory personnel play a crucial role in accurately performing the tests and reporting the results.
In simple words: This code indicates that a blood test showed unusual results related to how your blood clots.It could mean your blood clots too slowly or too quickly.
Abnormal coagulation profile. This encompasses various abnormalities in blood clotting factors, including:* Abnormal or prolonged bleeding time* Abnormal or prolonged coagulation time* Abnormal or prolonged partial thromboplastin time (PTT)* Abnormal or prolonged prothrombin time (PT)* Low von Willebrand factor
Example 1: A patient on anticoagulant therapy has a routine PT/INR check, and the result is significantly elevated, suggesting a higher risk of bleeding. However, the patient is not currently experiencing any bleeding complications. In this case, R79.1 would be used to document the abnormal coagulation profile., A patient presents with easy bruising and prolonged bleeding after minor injuries.Blood tests reveal a prolonged PTT, but further investigations are needed to determine the underlying cause, such as hemophilia or von Willebrand disease. R79.1 can be used as a preliminary code until a definitive diagnosis is established., During a pre-operative workup, a patient's coagulation profile shows a low von Willebrand factor.This finding indicates an increased bleeding risk during surgery. R79.1 is used to document this abnormality, and appropriate measures can be taken to mitigate the risk.
Documentation should include the specific coagulation test results (e.g., PT, INR, PTT, bleeding time, von Willebrand factor level) and any associated signs or symptoms, such as easy bruising, prolonged bleeding, or spontaneous bleeding. If the patient is on anticoagulant therapy, the medication name and dosage should also be documented.
** It is crucial to distinguish R79.1 from codes that describe active bleeding or coagulation defects.R79.1 signifies an abnormal laboratory finding, not necessarily a bleeding event or a diagnosed coagulation disorder. It’s also important to note that this code should not be used to describe prolonged PT/INR or PTT values due to therapeutic anticoagulation when there is no bleeding.In such cases, Z79.01 (Long term (current) use of anticoagulants) is the appropriate code.
- Payment Status: Active
- Specialties:Hematology, internal medicine, family medicine, cardiology, oncology, surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Independent Clinic, Emergency Room - Hospital,Ambulatory Surgical Center, Independent Laboratory, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home