Abnormal radiologic findings on diagnostic imaging of right testicle
ICD-10 R93.811 is a billable code used to indicate a diagnosis of abnormal radiologic findings on diagnostic imaging of right testicle.
R93.811 is used to classify abnormal findings observed on diagnostic imaging studies, such as ultrasound or CT scans, specifically concerning the right testicle. These findings may include but are not limited to masses, cysts, calcifications, or other anomalies that do not have a definitive diagnosis at the time of imaging. The abnormal findings can be indicative of various conditions, including testicular tumors, epididymitis, torsion, or trauma. It is crucial to note that this code does not specify the nature of the abnormality or its clinical significance, which necessitates further evaluation and possibly additional diagnostic testing. Clinicians must correlate these imaging findings with clinical symptoms, such as pain, swelling, or changes in testicular size, to determine the appropriate management plan. Accurate documentation of the imaging results, clinical context, and any subsequent evaluations is essential for proper coding and billing.
Documentation should include detailed imaging findings, clinical history, and any relevant physical examination results.
Patients presenting with scrotal pain or swelling, where imaging reveals abnormalities.
Ensure that the clinical context supports the need for imaging and that findings are clearly linked to the patient's symptoms.
Acute care documentation must include the reason for imaging, findings, and any immediate interventions taken.
Acute scrotal pain or trauma cases requiring urgent imaging.
Rapid assessment and documentation are critical; ensure that imaging findings are clearly communicated in the medical record.
When ultrasound is performed to evaluate abnormal findings.
Document the reason for the ultrasound and the findings.
Urologists may perform these studies more frequently.
Document the specific abnormal findings from the imaging, the clinical context, and any follow-up actions or recommendations made based on those findings.
