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R76.9 ICD-10-CM Code: Abnormal immunological finding in serum, unspecified

Billing Status: YES. This is a valid, specific, and billable ICD-10-CM reference.

Coding at a Glance

Tabular directives
7 Excludes2

Inpatient Payment Groups (MS-DRG)

Potential MS-DRG participation — not a DRG assignment.

MS-DRGs this diagnosis helps define, as principal or secondary, per the CMS ICD-10-CM/PCS MS-DRG Definitions Manual v43, Appendix B.

  • MS-DRG 814 — RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC (MDC 16)
  • MS-DRG 815 — RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC (MDC 16)
  • MS-DRG 816 — RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC (MDC 16)

A diagnosis appearing in a group's logic does not by itself determine the DRG assigned to a stay; the grouper uses the full claim.

Coding instructions

Official Tabular Instructional Notes: the inclusion, exclusion and sequencing notes published for R76.9 in the official ICD-10-CM tabular list, quoted as published.

Source: CMS/CDC — ICD-10-CM Tabular ListRelease: FY2026Effective: October 1, 2025

Notes without a marker are published on R76.9 itself; “inherited from” names the category or block whose note applies here.

Excludes2 — Not Included Here

Conditions not covered by this code, but which may be reported alongside it when both are present.

Source: inherited from R70-R79

Coder workflow for R76.9

MedCoder structured workflow — derived from this code’s own official record

Before you code R76.9

  1. Check whether an established diagnosis that explains this sign or symptom is documented. If one is, review whether the documented diagnosis changes the coding pathway: a symptom that is integral to a confirmed diagnosis is not reported separately, while one not routinely associated with it may be. Signs and symptoms are reported when no definitive diagnosis is established (Guidelines I.B.4, I.B.5, I.B.6, I.C.18.b).

    Guide: Symptom code vs confirmed diagnosis →

  2. Unspecified does not mean incorrect. When the record gives no greater specificity, R76.9 may be the appropriate code. Check the record for detail that supports a more specific sibling. An unspecified code is for records that do not provide the detail a more specific code needs; a query, not an assumption, is the route to specificity (Guidelines I.A.9.b, I.B.18).

    ReviewR76.0, R76.1, R76.8

    See the relationships section · Guide: Other vs unspecified (NEC vs NOS) →

Choose the right path

  1. Is an established diagnosis that explains this sign or symptom documented?
    Yes → Review whether the documented diagnosis changes the coding pathway: a symptom integral to it is not reported separately.
    No → Continue — the sign or symptom code stands when no definitive diagnosis is established.
  2. Does the record document the detail a more specific sibling code needs?
    Yes → Review the specific siblings in this subcategory.
    No → Continue — R76.9 is appropriate when the documentation goes no further.

    ReviewR76.0, R76.1, R76.8

Consider R76.9. Then confirm the code is valid for the date of service in the Verify section.

Documentation check

The provider’s diagnostic statement
Codes are assigned from the provider’s documented diagnosis, not from clinical criteria, test values or a medication list (Guidelines I.A.19).
Any detail beyond this code’s title
What the record states that a more specific sibling code would capture — or its absence, which itself supports the unspecified code.

Official instructions as workflow

  • Excludes2 — not part of R76.9(7 notes)

    Coding workflow: The conditions named in this note are not included in R76.9. When the record documents both, both may be reported; the note is a boundary, not a prohibition.

    CompareO28, E78, D69

    See the official tabular notes · Guidelines I.A.12.b

Coding decision scenarios

Pattern scenarios for this code’s structure — decision rules, not clinical cases

Documentation: The sign or symptom is documented, and the same record establishes a diagnosis that routinely includes it.

Coding question: Is R76.9 reported in addition to the diagnosis?

Path: Review the documented diagnosis and whether the classification treats this finding as integral to it.

Reason: Signs and symptoms integral to a confirmed diagnosis are not coded separately; those not routinely associated with it may be reported when present (Guidelines I.B.5, I.B.6, I.C.18.b).

Documentation: The provider documents the condition in the terms of this code’s title and records no further detail.

Coding question: Is a more specific sibling code supportable?

Path: Review the specific siblings in this subcategory and what each requires the record to state.

Reason: A more specific code needs documentation of the distinguishing element; without it the unspecified code is appropriate, and a provider query is the route to specificity (Guidelines I.A.9.b, I.B.18).

ReviewR76.0, R76.1, R76.8

Every row is derived from this code’s own record — its title, tabular notes, 7th-character family and same-category siblings — with fixed MedCoder wording; nothing is inferred about a patient. The official notes and guideline text are in the sections each row links to, and they control.

Code Overview

Abnormal immunological finding in serum, unspecified is a billable ICD-10-CM diagnosis code (R76.9).

MedCoder summary Summary composed by MedCoder from this code's official ICD-10-CM record. The tabular instructional notes themselves appear verbatim below.

Indexed Clinical Terms (1)

Official source data — entries quoted as published, in the Index’s own lookup phrasing

Clinical term phrases from the official ICD-10-CM Index to Diseases and Injuries that map to this code. These are alphabetic-index entries shown as the Index writes them — lookup phrasing, not necessarily the wording of a final diagnosis.

Verify Before Coding

  • No Medicare Code Editor or MS-DRG Definitions Manual restrictions apply to this code.

From the code registry, the Medicare Code Editor, and the MS-DRG Definitions Manual. Check it against a full claim in Claim Check.

Relationships & Classification

MedCoder structured relationships — computed from published CMS and AHRQ datasets

Other codes that name R76.9 or its code family, from the CMS ICD-10-CM tabular instructional notes. Tabular-note edges are stored at the code family level that carries each note.

Referenced by 8 Excludes2 notes: R83 — Abnormal findings in cerebrospinal fluid (via R76.-), R83-R89 — Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis (R83-R89) (via R76.-), R84 — Abnormal findings in specimens from respiratory organs and thorax (via R76.-), R85 — Abnormal findings in specimens from digestive organs and abdominal cavity (via R76.-), R86 — Abnormal findings in specimens from male genital organs (via R76.-), R87 — Abnormal findings in specimens from female genital organs (via R76.-), R88 — Abnormal findings in other body fluids and substances (via R76.-), R89 — Abnormal findings in specimens from other organs, systems and tissues (via R76.-).

These codes’ tabular lists name this diagnosis as distinct — both may be reported when both are documented.

MS-DRG Grouper Relationships (FY2026)

Potential MS-DRG participation — not a DRG assignment.

FY2026 MS-DRG: not on the CMS CC/MCC list — as a secondary diagnosis this code does not change MS-DRG severity for that release.

Named in the grouper logic of 3 MS-DRGs: DRG 814 (MDC 16), DRG 815 (MDC 16), DRG 816 (MDC 16).

From the CMS MS-DRG Definitions Manual (Appendices B and C). Actual DRG assignment depends on the complete claim.

Clinical classification (AHRQ CCSR):SYM017 — Abnormal findings without diagnosis (default).

Clinical Classifications Software Refined (CCSR) for ICD-10-CM Diagnoses. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Related Codes

Same clinical category (CCSR)

AHRQ's Clinical Classifications Software groups these diagnoses under the same clinical category (Abnormal findings without diagnosis).

R74.02 — Elevation of levels of lactic acid dehydrogenase [LDH], R74.8 — Abnormal levels of other serum enzymes, R74.9 — Abnormal serum enzyme level, unspecified, R75 — Inconclusive laboratory evidence of human immunodeficiency virus [HIV], R76.0 — Raised antibody titer, R76.11 — Nonspecific reaction to tuberculin skin test without active tuberculosis, R76.12 — Nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen response without active tuberculosis, R76.8 — Other specified abnormal immunological findings in serum, R76.81 — Abnormal rheumatoid factor and anti-citrullinated protein antibody without rheumatoid arthritis, R76.89 — Other specified abnormal immunological findings in serum, R77.0 — Abnormality of albumin, R77.1 — Abnormality of globulin, R77.2 — Abnormality of alphafetoprotein, R77.8 — Other specified abnormalities of plasma proteins, R77.9 — Abnormality of plasma protein, unspecified, R78.71 — Abnormal lead level in blood, R78.79 — Finding of abnormal level of heavy metals in blood, R78.81 — Bacteremia, R78.89 — Finding of other specified substances, not normally found in blood, R78.9 — Finding of unspecified substance, not normally found in blood, +183 more

Same Index main term, other category

The ICD-10-CM Index to Diseases and Injuries files this code under the main term “Abnormal, abnormality, abnormalities”; these codes share that main term but sit in a different category of the Tabular List.

R29.890 — Loss of height (loss of, height), R39.198 — Other difficulties with micturition (urination NEC), R63.2 — Polyphagia (increase in appetite), R63.4 — Abnormal weight loss (loss of, weight), R68.89 — Other general symptoms and signs (clinical findings NEC), R70.1 — Abnormal plasma viscosity (plasma, viscosity), R71.8 — Other abnormality of red blood cells (red blood cell), R73.09 — Other abnormal glucose (blood sugar), R74.8 — Abnormal levels of other serum enzymes (serum level, lipase), R74.9 — Abnormal serum enzyme level, unspecified (serum level, enzymes), R77.0 — Abnormality of albumin (albumin), R77.1 — Abnormality of globulin (globulin), R77.2 — Abnormality of alphafetoprotein (alphafetoprotein), R77.8 — Other specified abnormalities of plasma proteins (plasma, protein, specified NEC), R77.9 — Abnormality of plasma protein, unspecified (plasma, protein), R78.89 — Finding of other specified substances, not normally found in blood (blood level, lithium), R78.9 — Finding of unspecified substance, not normally found in blood (toxicology), R79.0 — Abnormal level of blood mineral (blood level, iron), R79.1 — Abnormal coagulation profile (bleeding time), R79.81 — Abnormal blood-gas level (blood-gas level), +237 more

Contextual Map

Every relationship of R76.9 in one view: hierarchy, official tabular instructions in both directions, clinical classification, risk adjustment, MS-DRG participation, index terms and change history — each edge carrying the CMS source it derives from.

Run R76.9 with these 8 related codes in Claim Check

Hierarchy

Referenced by Excludes2 notes

Clinical classification (CCSR)

MS-DRG Grouper

MDC crossing

  • MDC 16 — Diseases and Disorders of Blood, Blood Forming Organs and Immunologic Disorders[MDC crossing]: “Diseases and Disorders of Blood, Blood Forming Organs and Immunologic Disorders — the grouper's crossing between diagnoses and procedures: a principal diagnosis sets the MDC, and same-MDC procedures move the stay to its surgical DRGs. 1,614 same-MDC procedures group here; browse them on the MDC page.”— CMS MS-DRG Definitions Manual · FY2026

Index entries

  • Abnormal, abnormality, abnormalities, immunological findings, in serum[Index term]— CMS ICD-10-CM Index to Diseases and Injuries · icd10cm-fy2026

Nearest codes

Change history

  • FY2016 — In the code set at ICD-10-CM adoption [Change history]— CMS release files (code change ledger) · icd10cm-fy2016

Sources for this page

Codes, titles, notes, index terms and mappings on this page are transcribed from the datasets below. Relationships MedCoder computed and text MedCoder wrote are labelled where they appear.

Code, title, tabular notes and index terms Official source data
CMS/CDC ICD-10-CM FY2026 tabular list, index and tables, effective October 1, 2025 Release, file and checksum · Publisher’s page
Claim edits Official source data
CMS Definitions of Medicare Code Edits — v43.1 (April 2026) Release, file and checksum · Publisher’s page
Inpatient payment groups Official source data
CMS MS-DRG Definitions Manual (incl. Appendix B diagnosis index, Appendix C CC/MCC list, Appendix E procedure index) and IPPS Final Rule tables — v43 Release, file and checksum · Publisher’s page
Change history and date-of-service validity Official source data
CMS ICD-10-CM release addenda, ingested release by release into the change ledger Release, file and checksum · Publisher’s page
Comparisons, relationships and the contextual map MedCoder structured relationship
Computed by MedCoder from the tabular notes and tables above; every derived relationship is marked as derived where it appears
Summary and FAQ answers MedCoder explanation
Written by MedCoder to explain the sources above: drafted with AI assistance, checked by a person against the release files, and labelled as MedCoder text where it appears. Not official text.

Labels on this page: Official source data · MedCoder structured relationship · MedCoder explanation. How to read the labels · All data sources and release dates

Cite this page

Reference this page in a research guide, syllabus or article. The release is included because code content changes each year.

MedCoder.ai. "R76.9 — Abnormal immunological finding in serum, unspecified." ICD-10-CM FY2026. https://medcoder.ai/icd10/code/r76.9-abnormal-immunological-finding-in-serum-unspecified

Change history

  • FY2016 — October 1, 2015
    In the code set at ICD-10-CM adoption
    Abnormal immunological finding in serum, unspecified

No changes since FY2016 — additions, deletions, description changes and billable-status changes are tracked through FY2027 (effective October 1, 2026), and none are recorded for this code. Note changes are tracked from FY2027 only.

Nearest Codes in This Family

Official ICD-10-CM classifications closest to R76.9 in its code family, with their registry titles.

View all codes in the R76 family