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v1.0.0
ICD-10 Guide
ICD-10 CodesR76.8

R76.8

Other specified abnormal immunological findings in serum

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R76.8 is a billable code used to indicate a diagnosis of other specified abnormal immunological findings in serum.

Key Diagnostic Point:

R76.8 is used to classify abnormal immunological findings in serum that do not fall under more specific categories. These findings may include atypical results from immunological tests such as elevated or decreased levels of immunoglobulins, abnormal antibody responses, or unusual serum protein patterns. Such findings can indicate a variety of underlying conditions, including autoimmune disorders, immunodeficiencies, or infections. Clinicians may order immunological tests to evaluate a patient's immune status, diagnose conditions, or monitor treatment responses. Accurate interpretation of these results is crucial, as they can guide further diagnostic testing and management strategies. The code R76.8 serves as a catch-all for findings that are significant but not specifically classified elsewhere, necessitating careful documentation to support the diagnosis and ensure appropriate coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying conditions that can cause abnormal findings
  • Need for precise documentation to justify the use of this code
  • Potential overlap with other immunological codes
  • Variability in test results interpretation

Audit Risk Factors

  • Insufficient documentation linking abnormal findings to clinical symptoms
  • Use of the code without appropriate diagnostic testing
  • Inconsistent coding practices across different providers
  • Failure to update codes based on new clinical findings

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed clinical history, lab results, and correlation with symptoms.

Common Clinical Scenarios

Patients presenting with unexplained fatigue, recurrent infections, or autoimmune symptoms.

Billing Considerations

Ensure that all relevant lab tests are documented and that abnormal findings are clearly linked to the patient's clinical picture.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate lab results and clinical assessments.

Common Clinical Scenarios

Patients with acute allergic reactions or suspected immunological crises.

Billing Considerations

Rapid assessment and documentation are crucial; ensure that abnormal findings are noted in the context of acute presentations.

Coding Guidelines

Inclusion Criteria

Use R76.8 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when the abnormal immunological finding is documented and not classified elsewhere
  • The documentation must support the clinical significance of the findings

Exclusion Criteria

Do NOT use R76.8 When
No specific exclusions found.

Related CPT Codes

86001CPT Code

Immunology test, quantitative

Clinical Scenario

When performing immunological tests that yield abnormal results.

Documentation Requirements

Document the specific tests performed and their results.

Specialty Considerations

Ensure that the tests are relevant to the patient's clinical presentation.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of immunological findings, but it also requires more detailed documentation to support the use of codes like R76.8.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of immunological findings, but it also requires more detailed documentation to support the use of codes like R76.8.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of immunological findings, but it also requires more detailed documentation to support the use of codes like R76.8.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What types of lab tests might lead to the use of R76.8?

R76.8 may be used when lab tests such as immunoglobulin levels, antibody tests, or serum protein electrophoresis yield abnormal results that do not fit into more specific categories.