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  2. ICD-10-CM Codes List
  3. R00–R99
  4. R70-R79
  5. Findings of drugs and other substances, not normally found in blood (R78)

Findings of drugs and other substances, not normally found in blood (R78)

The ICD-10 code section R78 is used to document findings of drugs and other substances that are not normally present in the blood. This includes a variety of specific substances such as alcohol, opiates, cocaine, hallucinogens, and heavy metals, among others.

These codes help healthcare providers and medical coders precisely identify abnormal blood test results. For example, R78.0 corresponds to detection of alcohol in the blood, also known as a "high ethanol level in blood," while R78.71 indicates an abnormal lead level, referred to as "blood lead level above reference range." Codes like R78.81 cover bacteremia, which is the presence of bacteria in the bloodstream identified by blood culture. The section also includes findings of psychotropic drugs, steroids, and various heavy metals. Using the correct ICD-10 code for specific substances ensures accurate documentation of lab findings that are essential for diagnosis and treatment management.

Instructional Notations

Use Additional Code

The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.

  • code to identify the any retained foreign body, if applicable Z18

Type 2 Excludes

A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

  • mental or behavioral disorders due to psychoactive substance use F10 F19

Clinical Terms

The following clinical terms provide additional context, helping users better understand the clinical background and common associations for each diagnosis listed in this section. Including related terms alongside ICD-10-CM codes supports coders, billers, and healthcare professionals in improving accuracy, enhancing documentation, and facilitating research or patient education.

Bacteremia

The presence of viable bacteria circulating in the blood. Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia. The majority of cases are seen in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to invasion.

Hemorrhagic Septicemia

Any of several bacterial diseases, usually caused by PASTEURELLA MULTOCIDA, marked by the presence of hemorrhagic areas in the subcutaneous tissues, serous membranes, muscles, lymph glands, and throughout the internal organs. The diseases primarily affect animals and rarely humans.

Pasteurella multocida

A species of gram-negative, facultatively anaerobic, rod-shaped bacteria normally found in the flora of the mouth and respiratory tract of animals and birds. It causes shipping fever (see PASTEURELLOSIS, PNEUMONIC); HEMORRHAGIC BACTEREMIA; and intestinal disease in animals. In humans, disease usually arises from a wound infection following a bite or scratch from domesticated animals.