ICD-10 Guide

R93.89

Abnormal findings on diagnostic imaging of other specified body structures

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R93.89 is a billable code used to indicate a diagnosis of abnormal findings on diagnostic imaging of other specified body structures.

Key Diagnostic Point:

The ICD-10 code R93.89 is used to classify abnormal findings on diagnostic imaging that do not fall into more specific categories. This code encompasses a wide range of abnormal results from imaging studies such as X-rays, CT scans, MRIs, and ultrasounds that indicate potential pathology in various body structures. Common findings may include incidentalomas, structural anomalies, or unexpected lesions that require further evaluation. The clinical significance of these findings can vary widely, from benign conditions that require no intervention to serious pathologies that necessitate immediate medical attention. Accurate documentation of the imaging findings, the clinical context, and any follow-up actions taken is crucial for proper coding and reimbursement. Coders must ensure that the findings are clearly linked to the patient's clinical presentation and that any subsequent diagnostic or therapeutic actions are documented to support the use of this code.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of potential findings that can be coded under this category
Need for precise documentation linking findings to clinical scenarios
Differentiation from other codes that may seem similar
Potential for incidental findings that may not require further action

Audit Risk Factors

Inadequate documentation linking imaging findings to clinical symptoms
Failure to specify the body structure involved
Use of the code without appropriate follow-up actions documented
Misinterpretation of incidental findings as significant

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Documentation must include the specific imaging findings, clinical context, and any follow-up plans.

Common Clinical Scenarios

Patients presenting with vague symptoms where imaging reveals unexpected findings.

Billing Considerations

Ensure that the findings are clearly linked to the patient's symptoms to avoid coding errors.

Emergency Medicine

Documentation Requirements

Acute care documentation must detail the urgency of the findings and any immediate interventions.

Common Clinical Scenarios

Patients with acute pain where imaging reveals abnormalities requiring urgent care.

Billing Considerations

Document the rationale for imaging and any immediate follow-up actions taken.

Coding Guidelines

Inclusion Criteria

Use R93.89 When

According to the official coding guidelines, R93
89 should be used when the abnormal findings are not classified elsewhere and must be supported by clinical documentation that justifies the need for imaging and any subsequent actions taken

Exclusion Criteria

Do NOT use R93.89 When

No specific exclusions found.

Related CPT Codes

74176CPT Code

CT scan of abdomen and pelvis

Clinical Scenario

When a CT scan reveals abnormal findings in the abdomen.

Documentation Requirements

Document the reason for the scan and the findings.

Specialty Considerations

Ensure that the imaging findings are linked to the patient's symptoms.

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, but R93.89 remains a necessary code for findings that do not fit into more specific categories. Coders must be diligent in ensuring accurate documentation to support the use of this code.

ICD-9 vs ICD-10

Reimbursement & Billing Impact

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 R93.89?

Use R93.89 when there are abnormal findings on diagnostic imaging that do not fit into more specific categories and are documented appropriately.

ICD-10 R93.89 is a billable code used to indicate a diagnosis of abnormal findings on diagnostic imaging of other specified body structures.