Elevated INR (R79.1): Clinical Documentation & ICD-10 Coding Guide for Abnormal Coagulation

Updated on: July 26, 2025

The International Normalized Ratio (INR) is a critical lab value used to assess the clotting tendency of blood, especially in patients on anticoagulant therapy like warfarin. An elevated INR increases the risk of bleeding and requires timely intervention. The ICD-10 code R79.1 is used to document an abnormal coagulation profile, including an elevated INR when the underlying cause is unspecified or under investigation.

This guide explains when and how to use R79.1, best practices in documentation, and clinical implications for managing elevated INR in outpatient and inpatient settings.

What Is ICD-10 Code R79.1?

R79.1 is used when:

• A lab test reveals an abnormal INR or PT (prothrombin time)

• The underlying cause or diagnosis is not yet confirmed

• INR is elevated above therapeutic range

• It’s an incidental or asymptomatic finding or under active evaluation

It reflects a lab abnormality, not a disease—and should be used with clinical correlation or while awaiting definitive diagnosis.

Common Scenarios for Elevated INR

INR Ranges and Clinical Relevance

When to Use R79.1

Use R79.1 when:

• INR is elevated but no active bleeding or definitive diagnosis exists

• You are adjusting warfarin dose due to lab result

• INR elevation is incidental and under investigation

• No coagulopathy, liver disease, or medication error is yet confirmed

Documentation Tips for Elevated INR (R79.1)

Include the following in your clinical note:

• Lab values: Include exact INR (e.g., “INR = 4.2 on 3/15”)

• Anticoagulant status: Mention if patient is on warfarin or DOACs

• Clinical symptoms: Note bleeding, bruising, or asymptomatic status

• Action taken: Dose adjustment, vitamin K, lab recheck

• Plan for reassessment: When and how INR will be re-evaluated

Sample EHR Note:

“INR elevated at 4.5. Patient on warfarin for atrial fibrillation. No bleeding noted. Plan: Hold 1 dose, reduce weekly dose by 10%, recheck INR in 2 days. Diagnosis: Abnormal coagulation profile (R79.1) + Long-term anticoagulant therapy (Z79.01).”

SOAP Note Example – Elevated INR

• S: “Routine INR check; patient denies bleeding or bruising.”

• O: INR = 5.1; vitals stable; no signs of ecchymosis or hematuria

• A: Abnormal coagulation profile – Elevated INR (R79.1); on warfarin (Z79.01)

• P: Hold warfarin x1 day, recheck INR in 48 hours, counsel on bleeding signs

Comorbidities and Secondary Codes

When Not to Use R79.1

Patient Education Tips

• Explain the meaning of INR and its therapeutic range

• Review bleeding precautions:

  • Use soft-bristle toothbrush

  • Avoid NSAIDs and alcohol

  • Report any bleeding, bruising, dark stool

• Reinforce warfarin food interactions (vitamin K-rich foods)

• Schedule consistent INR testing

FAQs

Is R79.1 billable?

Yes. R79.1 is a valid and billable ICD-10 code for abnormal INR findings without bleeding or known diagnosis.

Can I use R79.1 for patients on DOACs?

Not typically. DOACs like apixaban and rivaroxaban are not monitored by INR, so use R79.1 only when coagulation abnormality is documented by other means.

Should I use R79.1 in post-op patients?

Only if the INR is documented as abnormal and clinically relevant during post-op labs.

Optimize Coagulation Documentation with DocScrib

With DocScrib’s AI-powered charting system, clinicians can:

✅ Automatically capture INR lab values and trigger R79.1 suggestions
✅ Log anticoagulant use and medication changes
✅ Link INR results to SOAP notes and care plans
✅ Improve billing accuracy and reduce claim rejections

🎯 Book your free demo now to streamline lab-based documentation and improve anticoagulation care.

Conclusion

ICD-10 Code R79.1 is essential when documenting elevated INR or abnormal coagulation profiles that have not yet been linked to a specific diagnosis or complication. With proper documentation, timely follow-up, and decision support from DocScrib, clinicians can ensure both clinical safety and coding accuracy in managing anticoagulated patients.