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ICD-10 Guide
ICD-10 CodesR78.3

R78.3

Finding of hallucinogen in blood

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

Code Description

ICD-10 R78.3 is a billable code used to indicate a diagnosis of finding of hallucinogen in blood.

Key Diagnostic Point:

The ICD-10 code R78.3 is used to indicate the presence of hallucinogens in the blood, which can be detected through various toxicology screenings. Hallucinogens are substances that alter perception, mood, and various cognitive processes. Common hallucinogens include LSD, psilocybin (magic mushrooms), and mescaline. The detection of these substances in the bloodstream can be indicative of substance use disorders, acute intoxication, or potential overdose. Symptoms associated with hallucinogen use may include visual or auditory hallucinations, altered sense of time, and significant changes in mood or behavior. Clinicians must consider the patient's history, presenting symptoms, and any co-occurring conditions when interpreting lab results. Accurate documentation of the clinical context surrounding the finding is crucial for appropriate coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in lab testing methods and interpretation
  • Need for comprehensive patient history to contextualize findings
  • Potential for co-occurring substance use disorders
  • Differentiation from other substance-related disorders

Audit Risk Factors

  • Inadequate documentation of clinical symptoms
  • Failure to link findings to specific patient history
  • Misinterpretation of lab results without clinical correlation
  • Coding without considering co-occurring conditions

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including substance use history and presenting symptoms.

Common Clinical Scenarios

Patients presenting with altered mental status or psychosis potentially related to hallucinogen use.

Billing Considerations

Consideration of comorbid psychiatric conditions and their impact on treatment.

Emergency Medicine

Documentation Requirements

Acute care documentation including vital signs, mental status examination, and lab results.

Common Clinical Scenarios

Patients presenting with acute intoxication or overdose symptoms.

Billing Considerations

Rapid assessment and intervention are critical; documentation must reflect urgency and clinical findings.

Coding Guidelines

Inclusion Criteria

Use R78.3 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used in conjunction with appropriate clinical documentation that supports the diagnosis and findings

Exclusion Criteria

Do NOT use R78.3 When
No specific exclusions found.

Related CPT Codes

80307CPT Code

Drug test, definitive

Clinical Scenario

Used when performing a definitive drug test that includes hallucinogens.

Documentation Requirements

Document the specific substances tested and the clinical rationale for testing.

Specialty Considerations

Ensure that the testing aligns with the clinical presentation and history.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of substance-related findings, improving the ability to track and manage substance use disorders effectively.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of substance-related findings, improving the ability to track and manage substance use disorders effectively.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of substance-related findings, improving the ability to track and manage substance use disorders effectively.

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 is the significance of finding hallucinogens in blood?

Finding hallucinogens in blood indicates recent use and can help guide treatment decisions, especially in emergency settings. It is crucial for understanding the patient's mental state and potential risks.