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ICD-10 Guide
ICD-10 CodesR78.71

R78.71

Abnormal lead level in blood

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

Code Description

ICD-10 R78.71 is a billable code used to indicate a diagnosis of abnormal lead level in blood.

Key Diagnostic Point:

Abnormal lead levels in blood indicate the presence of lead, a toxic heavy metal, in the bloodstream, which can result from various environmental and occupational exposures. Lead poisoning can lead to a range of health issues, including neurological impairment, developmental delays in children, and cardiovascular problems in adults. Symptoms may vary widely and can include abdominal pain, constipation, fatigue, headache, irritability, and in severe cases, seizures or coma. Laboratory findings typically involve blood lead level tests, with levels above 5 micrograms per deciliter (µg/dL) considered elevated in children. The clinical context for this code encompasses both acute and chronic exposure scenarios, necessitating careful evaluation of patient history, potential sources of exposure, and associated symptoms. Accurate diagnosis and management are crucial to prevent long-term health consequences, making this code significant in clinical practice.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptoms and clinical presentation
  • Need for thorough patient history to identify exposure sources
  • Differentiation from other heavy metal toxicities
  • Potential for co-morbid conditions affecting lead metabolism

Audit Risk Factors

  • Inadequate documentation of lead exposure sources
  • Failure to document clinical symptoms associated with lead levels
  • Misclassification of lead levels as normal when elevated
  • Lack of follow-up documentation for elevated lead levels

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Comprehensive patient history, including occupational and environmental exposure, and detailed clinical findings.

Common Clinical Scenarios

Patients presenting with nonspecific symptoms such as fatigue or abdominal pain, requiring lead level testing.

Billing Considerations

Consideration of chronic exposure effects and potential comorbidities that may complicate lead toxicity.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate symptoms, lead level results, and any interventions performed.

Common Clinical Scenarios

Patients with acute symptoms suggestive of lead poisoning, such as seizures or altered mental status.

Billing Considerations

Rapid assessment and intervention are critical; documentation should reflect urgency and treatment provided.

Coding Guidelines

Inclusion Criteria

Use R78.71 When
  • Follow official ICD
  • CM guidelines for coding abnormal findings, ensuring that the lead level is documented and correlates with clinical symptoms

Exclusion Criteria

Do NOT use R78.71 When
No specific exclusions found.

Related CPT Codes

83655CPT Code

Lead level test

Clinical Scenario

Used when a patient presents with symptoms suggestive of lead poisoning.

Documentation Requirements

Document the reason for testing and any symptoms present.

Specialty Considerations

In pediatrics, routine screening may be required based on age and risk factors.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of lead exposure and its effects, improving the accuracy of health records and facilitating better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of lead exposure and its effects, improving the accuracy of health records and facilitating better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of lead exposure and its effects, improving the accuracy of health records and facilitating better patient management.

Resources

Clinical References

  • •
    CDC Lead Poisoning Prevention

Coding & Billing References

  • •
    CDC Lead Poisoning Prevention

Frequently Asked Questions

What are the symptoms of elevated lead levels?

Symptoms can include abdominal pain, constipation, fatigue, headache, irritability, and in severe cases, seizures or coma. Symptoms may vary based on the level of exposure and individual susceptibility.