March 6, 2012

Abnormal Body Fluid Analysis: Coding in ICD-10-CM

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ICD-10-CM category R83–R89 codes classify abnormal findings on examination of “other” body fluids, substances and tissues, without diagnosis. Laboratory testing is performed on many types of body fluids other than blood, because samples such as urine, semen and amniotic fluid can provide more definitive diagnostic information.

 

Samples usually are obtained through collection of the fluid in a container (urine, semen, etc.) or by inserting a needle into a body cavity and aspirating with a syringe a portion of the fluid (pericardial or peritoneal fluid).

Once a sample is obtained, a variety of tests may be performed, including chemistry tests, microscopic examinations, genetic tests and infectious disease tests.

For certain body fluids, including pleural, pericardial and peritoneal fluids, it is important to determine through testing whether the fluid is transudate or an exudate because doing so can help diagnose the disease or condition present.

Transudate fluid

  • Caused by an imbalance between the pressure within blood vessels (which drives fluid out) and the amount of protein in blood (which keeps fluid in).
  • It is a clear fluid with a low protein concentration and a limited number of white blood cells.
  • Seen with conditions such as congestive heart failure and cirrhosis.

Exudate fluid

(Source: American Association for Clinical Chemistry, 2012, Paragraph 5)

Sources:

 

American Association for Clinical Chemistry, “Body Fluid Analysis” (Jan. 6, 2012). Retrieved from http://labtestsonline.org/understanding/analytes/body-fluid/tab/glance

Lolita M. Jones Consulting Services, “ICD-10-CM Core Concepts: A Chapter-by-Chapter Review of Coding Conventions and Challenges; Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99; pp. 18-17 and 18-18).

 

EXERCISE:

In order to prepare you for ICD-10-CM coding of abnormal body fluid analysis, the following exercise has been prepared as an educational tool.

A 2012 ICD-10-CM code book or an electronic file of the code book contents will be needed in order to use this coding manual. To access the 2012 ICD-10-CM code book electronic files, please go online to http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage.

Under the “Downloads” subhead, scroll down and download the folder titled “2012 Code Tables and Index [ZIP, 16.7MB] .” Once the folder is open, you will find several files, and you will need the following files when completing these exercises:

“ICD10CM_2012_Full_Tabular.pdf” – this is the 2012 ICD-10-CM Tabular List of Diseases and Injuries.

“ICD10CM_2012_Full_DIndex.pdf” – this is the 2012 ICD-10-CM Index to Diseases and Injuries.


 

EXERCISE:

Use the ICD-10-CM Index to Diseases and the tabular list to fill in the blanks with the appropriate ICD-10-CM codes. One row has been completed as an example. Do not code from this chart, as it is to be used for educational purposes only.

ABNORMAL FINDINGS ON EXAMINATION

BODY FLUID, SUBSTANCE OR TISSUE

Chromosomal

Cytological

Enzymes

Histological

Hormone Levels

Immunological

Microbiological

Amniotic fluid

 

 

 

 

 

 

 

Bronchial washings

 

 

 

 

 

 

 

Cerebrospinal fluid

 

 

 

 

 

 

 

Cervix uteri secretions

R87.89

R87.6-

R87.0

R87.7

R87.1

R87.4

R87.5

Cyst fluid

 

 

 

 

 

 

 

Middle ear fluid

 

 

 

 

 

 

 

Nasal secretions

 

 

 

 

 

 

 

Nipple discharge

 

 

 

 

 

 

 

Pericardial fluid

 

 

 

 

 

 

 

Peritoneal fluid

 

 

 

 

 

 

 

 


 

 

ABNORMAL FINDINGS ON EXAMINATION

BODY FLUID, SUBSTANCE OR TISSUE

Chromosomal

Cytological

Enzymes

Histological

Hormone Levels

Immunological

Microbiological

Pleural fluid

 

 

 

 

 

 

 

Prostatic secretions

 

 

 

 

 

 

 

Saliva

 

 

 

 

 

 

 

Seminal fluid

 

 

 

 

 

 

 

Sputum

 

 

 

 

 

 

 

Sweat

 

 

 

 

 

 

 

Synovial fluid

 

 

 

 

 

 

 

Throat scrapings

 

 

 

 

 

 

 

Vaginal secretions

 

 

 

 

 

 

 

Vulva secretions

 

 

 

 

 

 

 

Wound secretions

 

 

 

 

 

 

 

 


 

ANSWER KEY

 

EXERCISE: Use the ICD-10-CM Index to Diseases and the tabular list to fill in the blanks with the appropriate ICD-10-CM codes. The first row has been completed as an example. Do not code from this chart, as it is to be used for educational purposes only.

 

ABNORMAL FINDINGS ON EXAMINATION

BODY FLUID, SUBSTANCE OR TISSUE

Chromosomal

Cytological

Enzymes

Histological

Hormone Levels

Immunological

Microbiological

Amniotic fluid

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

Bronchial washings

R84.8

R84.6

R84.0

R84.7

R84.1

R84.4

R84.5

Cerebrospinal fluid

R83.8

R83.6

R83.0

R83.8

R83.1

R83.4

R83.5

Cervix uteri secretions

R87.89

R87.6-

R87.0

R87.7

R87.1

R87.4

R87.5

Cyst fluid

R88.8

R88.8

R88.8

R88.8

R88.8

R88.8

R88.8

Middle ear fluid

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

Nasal secretions

R84.8

R84.6

R84.0

R84.7

R84.1

R84.4

R84.5

Nipple discharge

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

Pericardial fluid

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

Peritoneal fluid

R89.8

R85.69

R85.0

R85.7

R85.1

R85.4

R85.5

 


 

 

ABNORMAL FINDINGS ON EXAMINATION

BODY FLUID, SUBSTANCE OR TISSUE

Chromosomal

Cytological

Enzymes

Histological

Hormone Levels

Immunological

Microbiological

Pleural fluid

R84.8

R84.6

R84.0

R84.7

R84.1

R84.4

R84.5

Prostatic secretions

R86.8

R86.6

R86.0

R86.7

R86.1

R86.4

R86.5

Saliva

R89.8

R85.69

R85.0

R85.7

R85.1

R85.4

R85.5

Seminal fluid

R86.8

R86.6

R86.0

R86.7

R86.1

R86.4

R86.5

Sputum

R84.8

R84.6

R84.0

R84.7

R84.1

R84.4

R84.5

Sweat

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

Synovial fluid

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

Throat scrapings

R84.8

R84.6

R84.0

R84.7

R84.1

R84.4

R84.5

Vaginal secretions

R87.89

R87.6-

R87.0

R87.7

R87.1

R87.4

R87.5

Vulva secretions

R87.89

R87.6-

R87.0

R87.7

R87.1

R87.4

R87.5

Wound secretions

R89.8

R89.6

R89.0

R89.7

R89.1

R89.4

R89.5

 

 

Lolita M. Jones, RHIA, CCS

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.