Abnormal sputum

This code signifies the presence of sputum that deviates from normal in appearance, consistency, or odor, without specific mention of blood. It indicates a non-specific abnormality in respiratory secretions that may suggest an underlying pulmonary or systemic issue. This finding is often noted during a physical examination or reported by the patient.

Use this code when documentation indicates abnormal sputum, such as purulent, frothy, tenacious, or discolored sputum (e.g., yellow, green, brown), without any mention of blood. This code is appropriate when the provider notes "abnormal sputum" or describes its atypical characteristics without a more specific diagnosis. Supporting documentation would include physician notes detailing the sputum's abnormal qualities.

• Do not use this code if the sputum is explicitly documented as blood-stained; refer to the Excludes1 note.
• Always seek a more specific diagnosis if the underlying cause of the abnormal sputum is identified (e.g., pneumonia, bronchitis).
• This code is often used as a sign/symptom code when a definitive diagnosis for the abnormal sputum has not yet been established.