2025 ICD-10-CM code R80.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Abnormal findings on examination of urine, without diagnosis - Proteinuria Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Persistent proteinuria, unspecified;persistent presence of excess protein in the urine, without a specified cause.
Medical necessity for further investigations into persistent proteinuria is established by the persistent presence of protein in the urine, indicating potential renal impairment.The need for additional testing and treatment is based on the severity of proteinuria and the patient's overall health.
The clinical responsibility for coding R80.1 rests with the physician or qualified healthcare professional who orders and interprets the urinalysis indicating persistent proteinuria.It is their responsibility to investigate the cause of the proteinuria and to document their findings thoroughly, enabling accurate coding.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R80-R82 (Abnormal findings on examination of urine, without diagnosis)
In simple words: This code means that a person has persistently high levels of protein in their urine, and the reason for this is unknown or hasn't been identified yet.
This ICD-10-CM code signifies persistent proteinuria without further specification of the underlying cause.Proteinuria refers to the presence of excessive protein in the urine, primarily albumin but also including globulins.The "persistent" qualifier indicates that the abnormal protein levels are ongoing rather than transient.The lack of further specification implies that the underlying etiology has not been determined or is not classifiable elsewhere.
Example 1: A 45-year-old male patient presents with persistent proteinuria detected during a routine check-up.Further investigation, including renal function tests and imaging, is inconclusive regarding the underlying etiology.Code R80.1 is assigned as the most appropriate., A 60-year-old female patient with a history of hypertension and diabetes mellitus is found to have persistent proteinuria during a follow-up appointment.While diabetes and hypertension may be contributing factors, a definitive diagnosis of a specific kidney disorder is not established. Code R80.1 is used pending further investigations., A 28-year-old female patient experiences persistent proteinuria during pregnancy. However, this is excluded from R80.1 per coding guidelines and should be coded using O12.1 (Gestational proteinuria).
Thorough documentation is crucial for accurate coding.The documentation must include:* Results of urinalysis demonstrating persistent proteinuria (quantification of protein levels is important).* History of the patient's symptoms and relevant medical history (e.g., hypertension, diabetes, kidney disease).* Results of any investigations undertaken to determine the underlying cause of proteinuria (e.g., renal function tests, kidney biopsy, imaging studies).* Physician's assessment and rationale for using code R80.1 (e.g., inconclusive findings, inability to establish a specific diagnosis).
** If there is evidence of a specific kidney disease or condition, a more specific ICD-10-CM code from other chapters should be used instead of R80.1.Always refer to the latest version of the ICD-10-CM coding manual and associated guidelines to ensure accurate and compliant coding.
- Payment Status: Active
- Specialties:Nephrology, Internal Medicine, Family Medicine
- Place of Service:Office, Hospital (Inpatient and Outpatient), Urgent Care, Clinic