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v1.0.0
ICD-10 Guide
ICD-10 CodesR82.998

R82.998

Other abnormal findings in urine

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R82.998 is a billable code used to indicate a diagnosis of other abnormal findings in urine.

Key Diagnostic Point:

R82.998 is used to classify abnormal findings in urine that do not fit into other specific categories. This code encompasses a variety of findings such as unusual constituents in urine, abnormal urine color, turbidity, or the presence of substances not typically found in normal urine. These findings may arise from various underlying conditions, including metabolic disorders, infections, or renal pathologies. For instance, the presence of glucose may indicate diabetes mellitus, while ketones could suggest diabetic ketoacidosis. Abnormal urine findings can also result from dehydration, hematuria, or urinary tract infections. Clinicians often order urinalysis as part of routine examinations or to investigate specific symptoms such as flank pain, dysuria, or changes in urinary habits. Accurate identification and coding of these findings are crucial for appropriate patient management and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying conditions
  • Overlap with other specific codes
  • Need for comprehensive clinical documentation
  • Potential for misinterpretation of lab results

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the nature of abnormal findings
  • Misuse of the code for more specific conditions
  • Lack of correlation between symptoms and lab results

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed clinical notes explaining the context of abnormal findings, including patient history and any relevant symptoms.

Common Clinical Scenarios

Patients presenting with nonspecific symptoms such as fatigue or weight loss, where urinalysis reveals abnormal findings.

Billing Considerations

Ensure that the relationship between abnormal findings and clinical symptoms is clearly documented to support the use of R82.998.

Emergency Medicine

Documentation Requirements

Acute care documentation must include the reason for urinalysis and any immediate clinical findings.

Common Clinical Scenarios

Patients with acute abdominal pain or hematuria presenting to the emergency department.

Billing Considerations

Rapid assessment and documentation are critical; ensure that all findings are recorded promptly to avoid coding errors.

Coding Guidelines

Inclusion Criteria

Use R82.998 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when the abnormal findings are not classified elsewhere
  • Document the clinical significance of the findings and any related symptoms

Exclusion Criteria

Do NOT use R82.998 When
No specific exclusions found.

Related CPT Codes

81001CPT Code

Urinalysis, automated, with microscopy

Clinical Scenario

Used when a urinalysis is performed to evaluate abnormal findings.

Documentation Requirements

Document the reason for the urinalysis and any relevant clinical findings.

Specialty Considerations

Ensure that the urinalysis results are clearly linked to the clinical diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of abnormal findings, which can improve the accuracy of patient records and facilitate better clinical decision-making.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal findings, which can improve the accuracy of patient records and facilitate better clinical decision-making.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abnormal findings, which can improve the accuracy of patient records and facilitate better clinical decision-making.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use R82.998?

Use R82.998 when you encounter abnormal findings in urine that do not fit into other specific categories and ensure that the clinical context is well documented.