Other and unspecified abnormal findings in urine
Chapter 18:Symptoms, signs and abnormal clinical findings
ICD-10 R82 is a billable code used to indicate a diagnosis of other and unspecified abnormal findings in urine.
The ICD-10 code R82 encompasses a range of abnormal findings in urine that do not fall under more specific categories. This may include findings such as abnormal urine color, turbidity, specific gravity, pH, presence of crystals, or other constituents that are not classified elsewhere. These findings can indicate various underlying conditions, including urinary tract infections, kidney disease, metabolic disorders, or dehydration. The clinical significance of these findings often requires further investigation to determine the underlying cause. For instance, hematuria (blood in urine) may suggest trauma or malignancy, while proteinuria (excess protein) can indicate kidney dysfunction. Accurate documentation of the specific abnormal findings is crucial for appropriate coding and subsequent management.
Detailed notes on the patient's history, physical examination findings, and any laboratory results related to urine analysis.
Patients presenting with nonspecific urinary symptoms, abnormal lab results during routine check-ups, or follow-up visits for chronic conditions.
Ensure that all abnormal findings are clearly documented and linked to the patient's clinical picture to support the use of R82.
Acute care documentation must include the patient's presenting symptoms, any immediate lab results, and the rationale for further testing.
Patients with acute abdominal pain, hematuria, or signs of urinary tract infection presenting to the emergency department.
In emergency settings, rapid assessment and documentation of abnormal findings are critical for appropriate coding and treatment.
Used when performing a urinalysis that reveals abnormal findings.
Document the type of urinalysis performed and the findings.
Ensure that the urinalysis results are clearly linked to the clinical symptoms for accurate coding.
Use R82 when the abnormal findings in urine cannot be classified under more specific codes like R80 or R81, and ensure that the clinical context is well documented.
