Abnormal findings on examination of urine, without diagnosis
ICD-10 Codes (24)
R81R82R82.0R82.1R82.2R82.3R82.4R82.5R82.6R82.7R82.71R82.79R82.8R82.81R82.89R82.9R82.90R82.91R82.99R82.991R82.992R82.993R82.994R82.998Updates & Changes
FY 2026 Updates
Deleted Codes
No codes deleted in this range for FY 2026
No significant changes for FY 2026
This range maintains stability with current coding practices
Historical Changes
- •FY 2025: Routine maintenance updates with minor terminology clarifications
- •FY 2024: Enhanced specificity requirements for certain code ranges
- •FY 2023: Updated documentation guidelines for improved clarity
Upcoming Changes
- •Proposed updates pending review by Coordination and Maintenance Committee
- •Under consideration: Enhanced digital health integration codes
Implementation Guidance
- •Review all FY 2026 updates for R80-R82 codes before implementation
- •Always verify the most current codes in the ICD-10-CM manual
- •Ensure clinical documentation supports the selected diagnosis codes
- +3 more guidance items...
Range Overview
The ICD-10 code range R80-R82 pertains to abnormal findings on examination of urine, without a formal diagnosis. These codes are used to document various abnormalities detected in urine tests, such as proteinuria, hematuria, and other abnormal chemical and microscopic findings. They are typically used in situations where further diagnostic investigation is needed, or where the abnormality is transient or not severe enough to warrant a more specific diagnosis.
Key Usage Points:
- •Use R80 codes for proteinuria, including isolated, orthostatic, and unspecified.
- •Use R81 for bilirubinuria, indicating the presence of bilirubin in the urine.
- •R82 codes cover other and unspecified findings in urine, including abnormal color, odor, and chemical contents.
- •These codes are not used for confirmed diagnoses, only for abnormal findings.
- •Always code to the highest level of specificity available.
Coding Guidelines
When to Use:
- ✓When a urine test shows abnormal levels of protein, use an R80 code.
- ✓Use R81 when bilirubin is detected in the urine.
- ✓For other abnormal chemical or microscopic findings in urine, use an R82 code.
- ✓When a urine test result is abnormal but the cause is unknown, use an R82 code.
- ✓Use these codes when the abnormality is not severe enough to warrant a more specific diagnosis.
When NOT to Use:
- ✗Do not use these codes for confirmed diagnoses.
- ✗Avoid using these codes when a more specific code is available.
- ✗Do not use these codes for normal findings on urine examination.
- ✗Avoid using these codes when the abnormality is due to a known, diagnosed condition.
- ✗Do not use these codes for abnormalities in other body fluids.
Code Exclusions
Always verify exclusions in the official ICD-10-CM guidelines and the patient's medical record.
Documentation Requirements
Proper documentation for R80-R82 codes should include the specific abnormal finding, its severity, and any relevant clinical context. If the abnormality is related to a known condition, this should also be documented.
Clinical Information:
- •Specific abnormal finding
- •Severity of the abnormality
- •Clinical context or symptoms
- •Related conditions, if any
- •Outcome of any further diagnostic testing
Supporting Evidence:
- •Lab reports showing abnormal findings
- •Clinical notes describing symptoms or context
- •Diagnostic reports, if applicable
- •Patient history and physical examination notes
Good Documentation Example:
Patient presented with lower abdominal pain. Urine test showed high levels of protein. Further diagnostic testing scheduled.
Poor Documentation Example:
Abnormal urine test.
Common Documentation Errors:
- ⚠Not specifying the abnormal finding
- ⚠Omitting clinical context or symptoms
- ⚠Not documenting related conditions
- ⚠Not including outcome of further diagnostic testing
Range Statistics
Coding Complexity
Coding for this range can be moderately complex due to the need to accurately identify the specific abnormal finding, assess its severity, and understand the clinical context. Related conditions and further diagnostic testing may also need to be considered.
Key Factors:
- ▸Determining the specific abnormal finding
- ▸Assessing the severity of the abnormality
- ▸Understanding the clinical context
- ▸Identifying related conditions
- ▸Following up on further diagnostic testing
Specialty Focus
These codes are commonly used in primary care, urology, and nephrology. They may also be used in emergency medicine and hospital medicine when abnormal urine findings are detected.
Primary Specialties:
Clinical Scenarios:
- • A patient presents with lower abdominal pain and a urine test shows high levels of protein.
- • During a routine check-up, a patient's urine test shows abnormal color.
- • A patient with a known kidney disorder has a urine test showing abnormal chemical contents.
- • A patient presents with urinary symptoms and a urine test shows the presence of bilirubin.
- • A patient's urine test shows microscopic abnormalities, but the cause is unknown.
Resources & References
Resources for coding in the R80-R82 range include the official ICD-10-CM guidelines, clinical reference materials, and educational resources for medical coding.
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Health Information Management Association (AHIMA) Coding Resources
- Centers for Disease Control and Prevention (CDC) ICD-10 resources
Clinical References:
- Lab Tests Online
- Merck Manual: Urinalysis
Educational Materials:
- American Academy of Professional Coders (AAPC) Educational Resources
- Medical Coding Academy
Frequently Asked Questions
Can R80-R82 codes be used for confirmed diagnoses?
No, these codes are used for abnormal findings on examination of urine, without a formal diagnosis. If a diagnosis has been confirmed, a more specific code should be used.