Abnormal level of substances chiefly nonmedicinal as to source in specimens from other organs, systems and tissues
ICD-10 R89.3 is a billable code used to indicate a diagnosis of abnormal level of substances chiefly nonmedicinal as to source in specimens from other organs, systems and tissues.
R89.3 is used to classify abnormal levels of substances that are primarily nonmedicinal in origin, detected in specimens obtained from various organs, systems, and tissues. This code encompasses a wide range of abnormal laboratory findings that do not fit neatly into other specific categories. Commonly, these findings may include elevated or decreased levels of substances such as hormones, enzymes, or metabolites that are not directly related to a specific disease process but may indicate underlying physiological disturbances. For instance, abnormal levels of electrolytes, proteins, or other biochemical markers can be indicative of metabolic imbalances, organ dysfunction, or systemic conditions. The clinical significance of these findings often requires further investigation to determine the underlying cause, which may involve additional diagnostic testing or clinical correlation with the patient's symptoms and medical history.
Documentation must include the specific abnormal findings, the context of the patient's clinical presentation, and any follow-up actions taken.
Patients presenting with unexplained fatigue, weight changes, or metabolic disturbances requiring laboratory evaluation.
Ensure that the abnormal findings are clearly linked to the patient's symptoms and that any relevant tests are documented.
Acute care documentation should detail the abnormal findings, immediate clinical implications, and any interventions performed.
Patients with acute metabolic derangements, such as hyperkalemia or hyponatremia, presenting with symptoms like arrhythmias or altered mental status.
Rapid assessment and documentation of abnormal lab results are critical in emergency settings.
Used when a comprehensive metabolic panel is ordered to evaluate abnormal findings.
Document the specific tests performed and the clinical rationale for ordering them.
Ensure that the panel is appropriate for the patient's clinical presentation.
Use R89.3 when you encounter abnormal levels of substances in lab results that do not fit into a more specific diagnosis and are not directly related to a known disease process.
