ICD-10 Guide

R84.5

Abnormal microbiological findings in specimens from respiratory organs and thorax

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R84.5 is a billable code used to indicate a diagnosis of abnormal microbiological findings in specimens from respiratory organs and thorax.

Key Diagnostic Point:

R84.5 is used to classify abnormal microbiological findings in specimens obtained from the respiratory organs and thorax, which may include sputum, bronchoalveolar lavage, pleural fluid, or lung biopsy samples. These findings can indicate the presence of pathogens such as bacteria, viruses, fungi, or atypical cells that may not be classified elsewhere. Symptoms associated with these findings can include cough, dyspnea, chest pain, fever, and hemoptysis. The abnormal results may suggest infections like pneumonia, tuberculosis, or fungal infections, as well as non-infectious conditions such as malignancies or autoimmune disorders. Accurate identification and documentation of these findings are crucial for appropriate treatment and management, as well as for coding purposes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of potential underlying conditions (infectious vs. non-infectious)
Need for precise documentation of specimen type and findings
Differentiation between similar codes for respiratory findings
Potential for overlapping symptoms with other respiratory codes

Audit Risk Factors

Inadequate documentation of the specific microbiological findings
Failure to link abnormal findings to clinical symptoms
Misclassification of findings as normal or non-specific
Inconsistent use of terminology in lab reports

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed clinical history, laboratory results, and treatment plans must be documented. Specifics about the type of specimen and the findings should be included.

Common Clinical Scenarios

Patients presenting with chronic cough, fever, or unexplained respiratory symptoms requiring microbiological evaluation.

Billing Considerations

Ensure that all relevant clinical information is captured to support the diagnosis and the necessity of the tests performed.

Emergency Medicine

Documentation Requirements

Acute care documentation must include the patient's presenting symptoms, initial assessment, and any immediate interventions taken based on lab findings.

Common Clinical Scenarios

Patients with acute respiratory distress or suspected pneumonia requiring rapid microbiological assessment.

Billing Considerations

Timeliness of documentation is critical in emergency settings; ensure that findings are documented promptly to support coding.

Coding Guidelines

Inclusion Criteria

Use R84.5 When

Follow the official ICD
CM coding guidelines, ensuring that the code is used only when there is clear documentation of abnormal microbiological findings from respiratory specimens
Coders should verify that the findings are not classified under other specific codes

Exclusion Criteria

Do NOT use R84.5 When

No specific exclusions found.

Related CPT Codes

87070CPT Code

Culture, bacterial, any source

Clinical Scenario

Used when a culture is performed to identify pathogens in respiratory specimens.

Documentation Requirements

Document the type of specimen and the clinical indication for the culture.

Specialty Considerations

Internal medicine and infectious disease specialists often order these tests.

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 data collection and reimbursement processes. R84.5 provides a clear classification for abnormal microbiological findings that were previously less defined.

ICD-9 vs ICD-10

Reimbursement & Billing Impact

reimbursement processes. R84.5 provides a clear classification for abnormal microbiological findings that were previously less defined.

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 specimens are included under R84.5?

R84.5 includes specimens such as sputum, bronchoalveolar lavage, pleural fluid, and lung biopsy samples that show abnormal microbiological findings.

ICD-10 R84.5 is a billable code used to indicate a diagnosis of abnormal microbiological findings in specimens from respiratory organs and thorax.