Abnormal serum enzyme level, unspecified
ICD-10 R74.9 is a billable code used to indicate a diagnosis of abnormal serum enzyme level, unspecified.
R74.9 is used to classify abnormal serum enzyme levels that are not specified in the clinical documentation. Serum enzymes are proteins that catalyze biochemical reactions and are often released into the bloodstream when tissues are damaged or diseased. Common enzymes measured include alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and creatine kinase (CK). Abnormal levels can indicate a variety of conditions, including liver disease, myocardial infarction, muscle disorders, and more. The unspecified nature of this code means that while an abnormal enzyme level has been identified, the specific enzyme or the underlying cause has not been documented, necessitating further investigation. Clinicians may order additional tests or imaging studies to determine the cause of the abnormality, and it is crucial for coders to ensure that the documentation supports the use of this code, as it may lead to further diagnostic coding.
Clear documentation of the clinical context surrounding the abnormal enzyme level, including any symptoms, history, and follow-up plans.
Patients presenting with fatigue, jaundice, or unexplained abdominal pain may have abnormal enzyme levels requiring further evaluation.
Ensure that all relevant lab results are included in the medical record to support the diagnosis.
Detailed documentation of acute symptoms, lab results, and any immediate interventions taken.
Patients presenting with chest pain or acute abdominal pain may have abnormal enzyme levels indicating potential myocardial infarction or pancreatitis.
Rapid assessment and documentation are critical in emergency settings to justify the use of this code.
Used when a comprehensive metabolic panel is ordered, which may include enzyme levels.
Ensure that the lab results are documented and linked to the clinical findings.
Internal medicine may frequently order these panels for routine check-ups.
Use R74.9 when there is documentation of an abnormal serum enzyme level, but the specific enzyme or underlying condition has not been identified. Ensure that further diagnostic workup is planned or has been performed.
