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ICD-10 Guide
ICD-10 CodesR86

R86

Abnormal findings in specimens from male genital organs

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

Code Description

ICD-10 R86 is a billable code used to indicate a diagnosis of abnormal findings in specimens from male genital organs.

Key Diagnostic Point:

The ICD-10 code R86 is used to classify abnormal findings in specimens obtained from male genital organs, which may include abnormal results from biopsies, cytological examinations, or other laboratory analyses. These findings can indicate a variety of conditions, including infections, neoplasms, or inflammatory processes. Symptoms may include abnormal discharge, pain, or lesions in the genital area. Common causes of abnormal findings can range from sexually transmitted infections (STIs) to benign or malignant tumors. The diagnostic approach typically involves a thorough clinical history, physical examination, and appropriate laboratory tests, including urinalysis, cultures, and imaging studies. Accurate coding requires careful documentation of the findings and the context in which they were obtained, ensuring that the specific abnormality is clearly described to support the use of this code.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying conditions
  • Need for precise documentation of findings
  • Differentiation from other similar codes
  • Potential for overlapping symptoms with other diagnoses

Audit Risk Factors

  • Inadequate documentation of the clinical findings
  • Failure to specify the type of specimen analyzed
  • Misclassification of findings as normal when abnormal
  • Inconsistent coding across different providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed clinical notes regarding the patient's history, presenting symptoms, and the specific findings from laboratory tests.

Common Clinical Scenarios

Patients presenting with abnormal urinalysis results or abnormal prostate-specific antigen (PSA) levels.

Billing Considerations

Ensure that all relevant laboratory results are included in the documentation to support the diagnosis.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate findings, patient history, and any interventions performed.

Common Clinical Scenarios

Patients with acute scrotal pain or suspected testicular torsion requiring urgent evaluation.

Billing Considerations

Rapid assessment and documentation are critical; ensure that all findings are clearly noted to support coding.

Coding Guidelines

Inclusion Criteria

Use R86 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when there is clear documentation of abnormal findings from male genital specimens
  • The code should not be used for normal findings or findings that can be classified under more specific codes

Exclusion Criteria

Do NOT use R86 When
No specific exclusions found.

Related Codes

Child Codes

10 codes
R86.0
Abnormal level of enzymes in specimens from male genital organs
R86.1
Abnormal level of hormones in specimens from male genital organs
R86.2
Abnormal level of other drugs, medicaments and biological substances in specimens from male genital organs
R86.3
Abnormal level of substances chiefly nonmedicinal as to source in specimens from male genital organs
R86.4
Abnormal immunological findings in specimens from male genital organs
R86.5
Abnormal microbiological findings in specimens from male genital organs
R86.6
Abnormal cytological findings in specimens from male genital organs
R86.7
Abnormal histological findings in specimens from male genital organs
R86.8
Other abnormal findings in specimens from male genital organs
R86.9
Unspecified abnormal finding in specimens from male genital organs

Related CPT Codes

88142CPT Code

Cytopathology, cervical or vaginal, collected in preservative fluid

Clinical Scenario

Used when cytological analysis of specimens shows abnormal findings.

Documentation Requirements

Document the type of specimen and findings clearly.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of abnormal findings.

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 male genital health issues.

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 male genital health issues.

Reimbursement & Billing Impact

reimbursement.

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 R86 instead of a more specific code?

Use R86 when the findings are abnormal but do not fit into a more specific diagnosis or when the specific abnormality is not yet determined.