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ICD-10 Guide
ICD-10 CodesR83.3

R83.3

Abnormal level of substances chiefly nonmedicinal as to source in cerebrospinal fluid

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

Code Description

ICD-10 R83.3 is a billable code used to indicate a diagnosis of abnormal level of substances chiefly nonmedicinal as to source in cerebrospinal fluid.

Key Diagnostic Point:

R83.3 refers to the presence of abnormal levels of substances in the cerebrospinal fluid (CSF) that are not derived from medicinal sources. This can include a variety of substances such as proteins, glucose, and other metabolites that may indicate underlying pathological processes. Abnormal CSF findings can be indicative of various neurological conditions, infections, or metabolic disorders. Symptoms may vary widely depending on the underlying cause but can include headaches, neurological deficits, altered mental status, or signs of infection such as fever. Laboratory analysis of CSF is critical for diagnosis, and abnormal findings must be interpreted in the context of clinical symptoms and other diagnostic tests. Common causes of abnormal CSF levels include infections (e.g., meningitis), inflammatory conditions (e.g., multiple sclerosis), and metabolic disorders (e.g., diabetes). Accurate documentation of clinical findings and laboratory results is essential for appropriate coding and billing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying conditions
  • Need for precise laboratory results interpretation
  • Differentiation from other neurological disorders
  • Documentation of clinical context and symptoms

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to correlate lab results with symptoms
  • Misinterpretation of abnormal CSF findings
  • Incorrect coding due to overlapping symptoms

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed clinical history, neurological examination findings, and lab results must be documented.

Common Clinical Scenarios

Patients presenting with unexplained neurological symptoms, requiring CSF analysis.

Billing Considerations

Ensure correlation between clinical symptoms and CSF findings to support the diagnosis.

Emergency Medicine

Documentation Requirements

Acute care documentation must include vital signs, neurological status, and immediate lab results.

Common Clinical Scenarios

Patients with acute onset of severe headache, fever, or altered mental status.

Billing Considerations

Rapid assessment and documentation are crucial for timely diagnosis and treatment.

Coding Guidelines

Inclusion Criteria

Use R83.3 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when there is clear documentation of abnormal CSF findings and that these findings are not attributable to other conditions

Exclusion Criteria

Do NOT use R83.3 When
No specific exclusions found.

Related CPT Codes

62270CPT Code

Lumbar puncture

Clinical Scenario

Used to obtain CSF for analysis when R83.3 is suspected.

Documentation Requirements

Document indication for lumbar puncture, patient consent, and procedure details.

Specialty Considerations

Ensure compliance with procedural guidelines in neurology and emergency medicine.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the accuracy of diagnoses and treatment plans. R83.3 provides a clear designation for abnormal CSF findings, enhancing clinical communication.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the accuracy of diagnoses and treatment plans. R83.3 provides a clear designation for abnormal CSF findings, enhancing clinical communication.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the accuracy of diagnoses and treatment plans. R83.3 provides a clear designation for abnormal CSF findings, enhancing clinical communication.

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 substances are considered under R83.3?

R83.3 encompasses nonmedicinal substances found in cerebrospinal fluid, including proteins, glucose, and metabolites that may indicate various pathological conditions.