The landscape of medical coding is intricate, requiring precision and a deep understanding of diagnostic classifications. Within the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), code R76.8 stands out as a crucial identifier for “Other specified abnormal immunological findings in serum.” This code is particularly relevant when discussing serological results related to hepatitis B, specifically the hepatitis B surface antibody. This article delves into the specifics of ICD-10-CM code R76.8, its application to hepatitis B surface antibody, and its significance in medical billing and diagnostics.
Understanding ICD-10-CM Code R76.8
ICD-10-CM code R76.8 is categorized under “Other abnormal immunological findings in serum” within Chapter XVIII, “Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.” Designated as a billable and specific code, R76.8 is used for reimbursement purposes in medical claims. The code’s 2025 edition became effective on October 1, 2024, and it is the American modification of the international ICD-10 code. It’s important to note that international versions of ICD-10 R76.8 might differ.
R76.8 is applicable in scenarios indicating a “Raised level of immunoglobulins NOS” (Not Otherwise Specified). This broad definition encompasses various immunological findings, including specific instances of immunity indicated by serological tests.
R76.8 and Hepatitis B Surface Antibody: Indicating Immunity
Within the extensive list of approximate synonyms associated with R76.8, “Immunity to hepatitis b by positive serology” and “Immunity to hepatitis b, positive serology” are explicitly mentioned. This direct inclusion clarifies that code R76.8 is appropriately used when a patient’s serological test reveals a positive hepatitis B surface antibody (anti-HBs).
A positive hepatitis B surface antibody typically indicates immunity to the hepatitis B virus. This immunity can be acquired either through vaccination or recovery from a past hepatitis B infection. In both cases, the presence of anti-HBs signifies that the individual has developed protective antibodies and is generally considered immune to future hepatitis B infection.
Therefore, when coding for a patient who presents with a positive hepatitis B surface antibody result, and the clinical context aligns with indicating immunity rather than active infection or other hepatitis B related conditions, ICD-10-CM code R76.8 is the relevant and accurate choice. It effectively communicates the abnormal immunological finding – the presence of antibodies indicating immunity – in the patient’s serum.
Synonyms and Clinical Context
The list of approximate synonyms for R76.8 provides further context for its application. Beyond hepatitis B immunity, it includes conditions like “Elevated immunoglobulin level,” and “False-positive serological test for syphilis.” It also lists immunity to other diseases like Hepatitis A, Measles, Mumps, Rubella, Tetanus, Varicella, and Lyme disease when confirmed by positive serology.
This broad range underscores that R76.8 is not solely confined to hepatitis B but applies to various situations where abnormal immunological findings, particularly raised antibody levels indicating immunity, are detected in serum. However, when specifically addressing hepatitis B surface antibody positivity as a marker of immunity, R76.8 directly applies.
Code History and Stability
ICD-10-CM code R76.8 has been a stable code since its introduction in 2016. It was established as a new code in the first year of the non-draft ICD-10-CM (effective October 1, 2015 for claims with service dates on or after this date). Since then, through the 2025 edition, R76.8 has remained unchanged, indicating its continued relevance and accuracy in the ICD-10-CM coding system for specified abnormal immunological findings in serum, including hepatitis B surface antibody positivity indicative of immunity.
Conclusion
In summary, ICD-10-CM code R76.8 serves as the appropriate diagnosis code to use when documenting “immunity to hepatitis b by positive serology.” It accurately captures the finding of hepatitis B surface antibody in serum as an “Other specified abnormal immunological finding.” Understanding the specific applications of R76.8, particularly in the context of hepatitis B immunity, is crucial for accurate medical coding, claim processing, and effective communication of diagnostic information within the healthcare system.
