2025 ICD-10-CM code R93
Abnormal findings on diagnostic imaging of other body structures.
Medical necessity for the diagnostic imaging should be clearly documented, along with the rationale for using code R93 in the absence of a definitive diagnosis. This might include reasons like transient symptoms, patient refusal of further testing, or the inability to obtain a more precise diagnosis despite appropriate investigation.
The clinician is responsible for ensuring that all necessary investigations have been performed to arrive at the most specific diagnosis possible.If a more specific diagnosis cannot be made, this code may be used, but it is crucial to document the reasons why a more definitive diagnosis could not be determined.
In simple words: This code indicates that an imaging test (like an X-ray, ultrasound, CT scan, or MRI) showed something unusual in a part of your body, but doctors haven't yet figured out exactly what's wrong.
This code represents nonspecific abnormal findings on diagnostic imaging (X-ray, ultrasound, CT, MRI, PET, thermography) of body structures not otherwise specified.It is used when a more specific diagnosis cannot be made after investigation, the symptoms are transient, further investigation is not possible, or a definitive diagnosis is unavailable for other reasons.
Example 1: A patient presents with abdominal pain. An ultrasound reveals an abnormality in the structure of an organ, but it is not clear what the abnormality represents. Further investigation is required to determine a specific diagnosis., A patient undergoes a routine chest X-ray, which shows an unusual shadow.Follow-up CT scans are inconclusive, and the patient is lost to follow-up.In the absence of a definitive diagnosis, R93 may be used to code the abnormal finding., A patient presents with transient shortness of breath. A lung perfusion scan reveals an abnormality. However, the symptoms resolve within a few days, and the patient declines further investigation. Because the symptoms were temporary and the cause couldn't be confirmed, R93 is an acceptable code.
Documentation should include the results of the diagnostic imaging study, the specific body structure involved, and the reason why a more specific diagnosis could not be established. Any additional symptoms or relevant clinical findings should also be noted.
** Code R93 is a general code for abnormal findings on diagnostic imaging when a more specific diagnosis isn't available.It's essential to use this code only after reasonable attempts have been made to determine a more specific diagnosis and to thoroughly document the reasons why this was not possible.
- Specialties:Radiology, any specialty ordering and interpreting diagnostic imaging.
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, other places where diagnostic imaging is performed.