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ICD-10 Guide
ICD-10 CodesR94.09

R94.09

Abnormal results of other function studies of central nervous system

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

Code Description

ICD-10 R94.09 is a billable code used to indicate a diagnosis of abnormal results of other function studies of central nervous system.

Key Diagnostic Point:

R94.09 is used to classify abnormal results from various function studies of the central nervous system (CNS) that do not fall under more specific categories. These studies may include electroencephalograms (EEGs), evoked potentials, and other neurophysiological tests that assess the functional integrity of the CNS. Abnormal findings may indicate a range of neurological disorders, including epilepsy, multiple sclerosis, or other neurodegenerative diseases. Symptoms associated with these findings can vary widely, including seizures, cognitive dysfunction, sensory deficits, and motor impairments. The interpretation of these tests requires a comprehensive understanding of the patient's clinical history, presenting symptoms, and other diagnostic findings to establish a clear clinical picture and guide further management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying conditions leading to abnormal results.
  • Need for comprehensive clinical documentation to support the diagnosis.
  • Differentiation from other similar codes that may apply.
  • Potential for overlapping symptoms with other neurological disorders.

Audit Risk Factors

  • Inadequate documentation of the clinical rationale for testing.
  • Failure to link abnormal findings to specific symptoms or diagnoses.
  • Misinterpretation of test results leading to incorrect coding.
  • Lack of follow-up documentation to support ongoing treatment.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, clinical findings, and rationale for testing must be documented.

Common Clinical Scenarios

Patients presenting with unexplained neurological symptoms such as headaches, dizziness, or cognitive changes.

Billing Considerations

Ensure that all relevant clinical findings are documented to support the use of R94.09.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate clinical findings and the urgency of the situation.

Common Clinical Scenarios

Patients presenting with acute neurological deficits or altered mental status requiring immediate evaluation.

Billing Considerations

Rapid assessment and documentation of symptoms are critical for accurate coding.

Coding Guidelines

Inclusion Criteria

Use R94.09 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used only when the abnormal results are not classified elsewhere and are clinically relevant to the patient's condition

Exclusion Criteria

Do NOT use R94.09 When
No specific exclusions found.

Related CPT Codes

95816CPT Code

Electroencephalogram (EEG)

Clinical Scenario

When an EEG is performed and shows abnormal results, R94.09 may be used to document the findings.

Documentation Requirements

Document the reason for the EEG and the specific abnormal findings.

Specialty Considerations

Neurology specialists should ensure that the clinical context is clear.

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, improving the granularity of data collection and enhancing the ability to track and analyze neurological disorders.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the granularity of data collection and enhancing the ability to track and analyze neurological disorders.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of abnormal findings, improving the granularity of data collection and enhancing the ability to track and analyze neurological disorders.

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

What types of studies are included under R94.09?

R94.09 encompasses various function studies of the CNS, including EEGs, evoked potentials, and other neurophysiological assessments that yield abnormal results not classified elsewhere.