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ICD-10 Guide
ICD-10 CodesR77.9

R77.9

Abnormality of plasma protein, unspecified

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

Code Description

ICD-10 R77.9 is a billable code used to indicate a diagnosis of abnormality of plasma protein, unspecified.

Key Diagnostic Point:

R77.9 refers to an unspecified abnormality of plasma proteins, which are critical components of blood that play various roles including maintaining oncotic pressure, transporting substances, and participating in immune responses. Abnormalities in plasma proteins can manifest as either elevated or decreased levels of specific proteins, which may indicate underlying health issues. Common symptoms associated with plasma protein abnormalities may include edema, fatigue, and signs of liver dysfunction. Laboratory findings may include altered serum protein electrophoresis results, abnormal albumin levels, or changes in globulin fractions. The clinical context for this code is broad, as it encompasses a variety of conditions that may not be specifically classified elsewhere, necessitating careful evaluation of patient history, clinical signs, and laboratory results to determine the underlying cause of the abnormality.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying conditions that can cause plasma protein abnormalities.
  • Need for comprehensive laboratory evaluation to determine specific abnormalities.
  • Potential overlap with other codes related to specific plasma protein disorders.
  • Documentation must clearly indicate the reason for testing and clinical findings.

Audit Risk Factors

  • Insufficient documentation to support the diagnosis of abnormal plasma proteins.
  • Failure to specify the underlying condition leading to the abnormality.
  • Inconsistent use of the code across different encounters.
  • Lack of correlation between clinical findings and laboratory results.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, clinical examination findings, and laboratory results must be documented to support the diagnosis.

Common Clinical Scenarios

Patients presenting with unexplained edema, fatigue, or signs of liver disease may undergo testing for plasma protein levels.

Billing Considerations

Internal medicine practitioners should ensure that the underlying cause of the abnormality is investigated and documented.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate clinical findings and rationale for laboratory tests ordered.

Common Clinical Scenarios

Patients presenting with acute symptoms such as jaundice or severe edema may require urgent evaluation of plasma proteins.

Billing Considerations

Emergency settings may necessitate rapid coding decisions; thus, clear documentation of acute findings is crucial.

Coding Guidelines

Inclusion Criteria

Use R77.9 When
  • Coders should refer to the official ICD
  • CM coding guidelines, ensuring that the code is used only when the abnormality is documented as unspecified and that all relevant clinical information is captured

Exclusion Criteria

Do NOT use R77.9 When
No specific exclusions found.

Related CPT Codes

84155CPT Code

Protein, total, serum

Clinical Scenario

Used when evaluating total protein levels in patients suspected of having plasma protein abnormalities.

Documentation Requirements

Document the clinical indication for the test and any relevant patient history.

Specialty Considerations

Internal medicine and nephrology often order this test to assess protein levels.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of plasma protein abnormalities, but R77.9 remains a catch-all for unspecified cases, necessitating careful documentation to avoid misuse.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of plasma protein abnormalities, but R77.9 remains a catch-all for unspecified cases, necessitating careful documentation to avoid misuse.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of plasma protein abnormalities, but R77.9 remains a catch-all for unspecified cases, necessitating careful documentation to avoid misuse.

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

When should R77.9 be used?

R77.9 should be used when there is an abnormality of plasma proteins documented, but the specific cause or type is not specified in the medical record.