Abnormal findings on cytological and histological examination of urine
ICD-10 R82.8 is a billable code used to indicate a diagnosis of abnormal findings on cytological and histological examination of urine.
R82.8 is used to classify abnormal findings identified during cytological and histological examinations of urine that do not fall under more specific categories. These findings may include atypical cells, abnormal cellular architecture, or other histological changes that suggest underlying pathology. Common causes of abnormal findings in urine cytology include urinary tract infections, malignancies (such as bladder cancer), and inflammatory conditions. The diagnostic approach typically involves obtaining a urine sample, which is then subjected to microscopic examination and may include additional tests such as urine culture or cytology. Clinicians must interpret these findings in the context of the patient's clinical history and symptoms, as abnormal results can indicate a range of conditions from benign to malignant. Accurate coding is essential for proper documentation and reimbursement, and coders must ensure that the findings are well-documented in the patient's medical record.
Detailed clinical history, including symptoms and prior urinary issues, must be documented. The rationale for the cytological examination should also be included.
Patients presenting with hematuria, recurrent urinary tract infections, or unexplained urinary symptoms.
Ensure that all findings are clearly linked to the patient's clinical presentation to avoid ambiguity in coding.
Acute care documentation must include the reason for the cytological examination and any immediate findings.
Patients with acute flank pain, gross hematuria, or signs of urinary obstruction.
In emergency settings, rapid documentation is crucial; ensure that all relevant findings are captured promptly.
Used when cytological examination is performed on urine samples.
Documentation must include the reason for the cytological examination and the findings.
Urology specialists may frequently use this code in conjunction with R82.8.
Documentation should include the clinical indication for the cytological examination, the specific findings noted, and any follow-up actions or diagnoses that arise from those findings.
