Abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladder
ICD-10 R93.41 is a billable code used to indicate a diagnosis of abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladder.
R93.41 is used to classify abnormal findings observed in diagnostic imaging studies of the renal pelvis, ureter, or bladder. These findings may include the presence of masses, stones, or structural abnormalities that are not classified elsewhere. Symptoms associated with these findings can range from hematuria (blood in urine), flank pain, dysuria (painful urination), to urinary obstruction. Common causes of abnormal findings include urinary tract infections, nephrolithiasis (kidney stones), tumors, or congenital anomalies. The diagnostic approach typically involves imaging modalities such as ultrasound, CT scans, or MRI, which help visualize the urinary tract and identify any abnormalities. It is crucial for healthcare providers to document the specific findings and correlate them with the patient's clinical symptoms to ensure accurate coding and appropriate management.
Documentation should include detailed descriptions of imaging findings, clinical correlation, and any relevant laboratory results.
Patients presenting with flank pain and hematuria undergoing imaging for suspected nephrolithiasis.
Ensure that the imaging findings are clearly linked to the patient's symptoms to avoid coding errors.
Acute care documentation must include the reason for imaging, findings, and any immediate interventions taken.
Patients with acute abdominal pain and suspected urinary obstruction requiring urgent imaging.
Rapid documentation is essential; ensure that all findings are recorded promptly to support coding.
Used when imaging is performed to evaluate for abnormalities in the renal pelvis, ureter, or bladder.
Document the reason for the CT scan, findings, and any follow-up recommendations.
Ensure that the imaging report is available for coding.
R93.41 should be used when there are abnormal findings on imaging of the renal pelvis, ureter, or bladder that are not classified elsewhere, and these findings must be documented in the patient's medical record.
