Abnormal findings on examination of urine, without diagnosis
ICD-10 Codes (26)
R91R91.1R91.8R92R92.0R92.1R92.2R92.3R92.30R92.31R92.311R92.312R92.313R92.32R92.321R92.322R92.323R92.33R92.331R92.332R92.333R92.34R92.341R92.342R92.343R92.8Updates & 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 R90-R92 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 R90-R92 pertains to abnormal findings on diagnostic imaging and in function studies, without diagnosis. These codes are used when abnormal results are found, but no definitive diagnosis is made. They cover a wide range of tests including radiological, ultrasound, and other imaging studies.
Key Usage Points:
- •Use these codes when abnormal findings are present, but no diagnosis is made.
- •These codes can be used for any imaging modality, including X-ray, CT, MRI, and ultrasound.
- •The codes are not specific to any body system or disease, making them versatile.
- •Do not use these codes if a definitive diagnosis is made.
- •These codes can be used in any healthcare setting where imaging studies are performed.
Coding Guidelines
When to Use:
- ✓When an abnormal finding is present on imaging, but no diagnosis is made.
- ✓When a patient has abnormal imaging results, but further testing is needed.
- ✓When a patient has abnormal imaging results, but no symptoms are present.
- ✓When a patient has abnormal imaging results, but the physician does not make a diagnosis.
When NOT to Use:
- ✗When a definitive diagnosis is made.
- ✗When the abnormal finding is expected or explained by a known condition.
- ✗When the abnormal finding is not significant or relevant to the patient's current condition.
- ✗When the abnormal finding is an incidental finding.
Code Exclusions
Always verify exclusions with the latest ICD-10-CM Official Guidelines for Coding and Reporting.
Documentation Requirements
Documentation for these codes should clearly indicate that an abnormal finding was identified on imaging, but no diagnosis was made. The specific imaging modality and area of the body should be documented.
Clinical Information:
- •Type of imaging modality used
- •Area of the body imaged
- •Description of the abnormal finding
- •Statement that no diagnosis was made
Supporting Evidence:
- •Imaging reports
- •Physician's notes
- •Laboratory results
Good Documentation Example:
Patient underwent CT scan of the abdomen due to persistent pain. Scan revealed an unexplained mass. No diagnosis made at this time.
Poor Documentation Example:
CT scan showed mass.
Common Documentation Errors:
- ⚠Not specifying the imaging modality
- ⚠Not indicating the area of the body imaged
- ⚠Not describing the abnormal finding
- ⚠Not stating that no diagnosis was made
Range Statistics
Coding Complexity
These codes require a moderate level of coding knowledge and experience. Coders must be able to understand the difference between an abnormal finding and a diagnosis, and know when to use these codes versus when to code for a specific condition. They must also be able to interpret imaging reports and physician's notes, and stay up-to-date with changes to the code set.
Key Factors:
- ▸Understanding the difference between an abnormal finding and a diagnosis
- ▸Knowing when to use these codes versus when to code for a specific condition
- ▸Being able to interpret imaging reports and physician's notes
- ▸Staying up-to-date with changes to the code set
Specialty Focus
These codes are most commonly used in radiology, but can be used in any specialty that utilizes imaging studies.
Primary Specialties:
Clinical Scenarios:
- • A patient with persistent abdominal pain undergoes a CT scan, which reveals an unexplained mass.
- • A patient with chest pain has an abnormal finding on a cardiac MRI, but no diagnosis is made.
- • A patient with a history of cancer has an abnormal finding on a follow-up PET scan, but no new diagnosis is made.
Resources & References
Resources for these codes include the ICD-10-CM Official Guidelines for Coding and Reporting, the American Health Information Management Association (AHIMA), and the American Academy of Professional Coders (AAPC).
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- AHIMA Coding Clinic
- AAPC Coding Edge
Clinical References:
- Radiology Society of North America
- American College of Radiology
Educational Materials:
- AHIMA ICD-10-CM Coding Workbook
- AAPC ICD-10-CM Training Manual
Frequently Asked Questions
Can I use these codes if a diagnosis is made?
No, these codes should only be used when an abnormal finding is present on imaging, but no diagnosis is made.