Unspecified abnormal findings in urine
ICD-10 R82.90 is a billable code used to indicate a diagnosis of unspecified abnormal findings in urine.
R82.90 is used to classify unspecified abnormal findings in urine that do not fall under a more specific diagnosis. This code encompasses a variety of potential abnormalities that may be detected during urinalysis, including but not limited to the presence of blood (hematuria), protein (proteinuria), glucose (glycosuria), ketones, or abnormal pH levels. These findings can indicate a range of underlying conditions, from urinary tract infections (UTIs) and kidney disease to metabolic disorders and systemic diseases. The lack of specificity in this code necessitates careful clinical evaluation to determine the underlying cause of the abnormal findings. Clinicians may order additional tests, such as urine cultures, imaging studies, or blood tests, to further investigate the etiology of the abnormalities. Accurate documentation of the clinical context, symptoms, and any follow-up actions taken is crucial for proper coding and billing.
Detailed clinical notes explaining the reason for urinalysis, findings, and any follow-up actions taken.
Patients presenting with symptoms such as flank pain, dysuria, or unexplained weight loss may undergo urinalysis, leading to abnormal findings.
Ensure that all relevant symptoms and potential underlying conditions are documented to support the use of R82.90.
Acute care documentation must include the patient's presenting symptoms, the rationale for urinalysis, and any immediate interventions.
Patients with acute abdominal pain or suspected renal colic may have urinalysis performed, revealing abnormal findings.
In emergency settings, rapid documentation is essential, but it must still capture the necessary details to justify the use of R82.90.
Used when performing a urinalysis that reveals abnormal findings.
Document the reason for the urinalysis and any abnormal findings noted.
In internal medicine, ensure that the clinical context is clear to support the findings.
R82.90 should be used when abnormal findings in urine are identified but do not fall under a more specific diagnosis. It is essential to ensure that the clinical documentation supports the use of this code.
