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ICD-10 Guide
ICD-10 CodesR82.5

R82.5

Elevated urine levels of drugs, medicaments and biological substances

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

Code Description

ICD-10 R82.5 is a billable code used to indicate a diagnosis of elevated urine levels of drugs, medicaments and biological substances.

Key Diagnostic Point:

R82.5 refers to the abnormal laboratory finding of elevated levels of drugs, medicaments, and biological substances in urine. This condition may arise from various factors, including medication use, substance abuse, or exposure to certain biological agents. Clinically, elevated urine drug levels can indicate therapeutic drug monitoring, potential overdose, or illicit drug use. Symptoms may vary based on the substance involved, but common signs include altered mental status, gastrointestinal disturbances, or cardiovascular symptoms. The diagnostic approach typically involves urine toxicology screening, which can identify specific substances present in the urine. It is crucial to correlate laboratory findings with clinical symptoms and patient history to determine the underlying cause and appropriate management. Accurate coding of R82.5 requires thorough documentation of the clinical context, including the substances detected and any relevant patient history.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of substances that can cause elevated levels
  • Need for correlation with clinical symptoms
  • Potential for multiple underlying causes
  • Variability in testing methods and interpretation

Audit Risk Factors

  • Inadequate documentation of substance levels
  • Failure to link elevated levels to clinical symptoms
  • Misinterpretation of urine drug screening results
  • Coding without confirming patient history

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including medication use and substance exposure.

Common Clinical Scenarios

Patients presenting with altered mental status or overdose symptoms.

Billing Considerations

Consideration of chronic conditions that may affect drug metabolism.

Emergency Medicine

Documentation Requirements

Acute care documentation, including time of substance exposure and clinical presentation.

Common Clinical Scenarios

Acute intoxication cases requiring immediate intervention.

Billing Considerations

Rapid assessment and documentation of vital signs and mental status.

Coding Guidelines

Inclusion Criteria

Use R82.5 When
  • Follow official ICD
  • CM guidelines for coding abnormal findings, ensuring that the clinical context is well
  • documented and that the code reflects the specific findings

Exclusion Criteria

Do NOT use R82.5 When
No specific exclusions found.

Related CPT Codes

80305CPT Code

Drug test, qualitative, multiple drugs, urine

Clinical Scenario

Used when urine toxicology screening is performed.

Documentation Requirements

Document the specific drugs tested and results.

Specialty Considerations

Ensure that the testing aligns with the 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 abnormal urine findings, enhancing the ability to capture the clinical nuances of elevated drug levels.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal urine findings, enhancing the ability to capture the clinical nuances of elevated drug levels.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abnormal urine findings, enhancing the ability to capture the clinical nuances of elevated drug levels.

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 should be documented to support the use of R82.5?

Documentation should include the specific substances detected, the clinical context, patient history, and any symptoms present at the time of testing.