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ICD-10 Guide
ICD-10 CodesR89.2

R89.2

Abnormal level of other drugs, medicaments and biological substances in specimens from other organs, systems and tissues

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

Code Description

ICD-10 R89.2 is a billable code used to indicate a diagnosis of abnormal level of other drugs, medicaments and biological substances in specimens from other organs, systems and tissues.

Key Diagnostic Point:

R89.2 is used to classify abnormal levels of drugs, medicaments, and biological substances found in specimens taken from various organs, systems, and tissues. This code is particularly relevant when laboratory tests reveal unexpected concentrations of substances that are not classified under more specific codes. Such findings may indicate potential toxicity, therapeutic failure, or the need for further investigation into the patient's medication regimen. Commonly tested substances include antibiotics, anticoagulants, and other therapeutic agents. The clinical significance of these abnormal levels can vary widely, necessitating a thorough review of the patient's history, current medications, and any recent changes in treatment. Accurate coding requires careful documentation of the laboratory findings, the context of the tests performed, and any associated symptoms or clinical conditions that may be relevant to the abnormal results.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of substances that can be tested and their potential effects
  • Need for comprehensive patient history to determine relevance
  • Potential overlap with other codes for drug levels
  • Documentation requirements for abnormal findings

Audit Risk Factors

  • Inadequate documentation of the clinical context
  • Failure to specify the substance involved
  • Misinterpretation of lab results leading to incorrect coding
  • Lack of follow-up documentation on patient outcomes

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient medication history, lab results, and clinical notes explaining the significance of abnormal findings.

Common Clinical Scenarios

Patients presenting with unexplained symptoms where drug levels are tested to rule out toxicity or therapeutic failure.

Billing Considerations

Consideration of polypharmacy and interactions between multiple medications.

Emergency Medicine

Documentation Requirements

Acute care documentation including immediate lab results, patient presentation, and any interventions performed.

Common Clinical Scenarios

Patients with acute symptoms potentially related to drug toxicity or overdose.

Billing Considerations

Rapid assessment and documentation are crucial in emergency settings to ensure accurate coding.

Coding Guidelines

Inclusion Criteria

Use R89.2 When
  • Coders should refer to the official ICD
  • CM guidelines for coding and reporting, ensuring that the abnormal findings are documented clearly and that the code is used in conjunction with any relevant symptoms or conditions

Exclusion Criteria

Do NOT use R89.2 When
No specific exclusions found.

Related CPT Codes

80307CPT Code

Drug testing, definitive

Clinical Scenario

Used when drug levels are tested in relation to symptoms.

Documentation Requirements

Documentation of the reason for testing and results.

Specialty Considerations

Internal medicine may require more detailed medication history.

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 ability to track and analyze drug-related issues in clinical practice.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the ability to track and analyze drug-related issues in clinical practice.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the ability to track and analyze drug-related issues in clinical practice.

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

When should R89.2 be used?

R89.2 should be used when laboratory tests indicate abnormal levels of drugs or biological substances that are not classified under more specific codes, and when these findings are clinically significant.