2025 ICD-10-CM code R93.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs, and abnormal clinical and laboratory findings - Abnormal findings on diagnostic imaging of other body structures Chapter 19: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Abnormal findings on diagnostic imaging of the liver and biliary tract, such as nonvisualization of the gallbladder.
Medical necessity is established by the presence of clinical symptoms or findings warranting the performance of diagnostic imaging to evaluate the liver and biliary tract.The use of code R93.2 is justified when the imaging reveals nonspecific abnormalities that require additional investigation before a specific diagnosis can be determined.
The clinical responsibility involves ordering and interpreting diagnostic imaging studies of the liver and biliary tract, correlating findings with patient history and physical exam, ordering further tests to elucidate the findings, and managing the patient accordingly.
- Chapter 19: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R90-R94: Abnormal findings on diagnostic imaging and in function studies, without diagnosis
In simple words: This code means that a doctor found something unusual in images (like X-rays, ultrasounds, or CT scans) of your liver or bile ducts, but they don't yet know what the problem is. More tests may be needed for a proper diagnosis.
This code is used to report nonspecific abnormal findings detected during diagnostic imaging procedures of the liver and biliary tract.These findings lack sufficient detail to assign a more specific diagnosis. Examples include nonvisualization of the gallbladder, unusual liver texture or size, or undefined masses or lesions. The code should only be used when a more definitive diagnosis is not possible even after all relevant investigations. It encompasses cases where the abnormality is transient, the etiology is unknown, or further investigation is pending but not readily available. This code is distinct from findings definitively indicating a specific disease elsewhere classified.
Example 1: A patient presents with vague abdominal pain. An ultrasound reveals an undefined mass in the liver.The physician documents the findings as "abnormal liver findings on ultrasound" pending further investigation (e.g., biopsy, MRI). R93.2 would be coded., During a routine health check-up, an abdominal CT scan shows nonvisualization of the gallbladder. Further testing is indicated to determine the cause. R93.2 would be appropriately assigned., A patient undergoes an MRI for suspected liver disease. The images reveal several indistinct lesions that are not easily characterized.After attempting to clarify with additional testing, a definitive diagnosis cannot be reached. R93.2 would be the best fit.
The medical record must document the imaging study performed (e.g., ultrasound, CT, MRI), detailed descriptions of the abnormal findings, and a clear statement indicating that further diagnostic evaluation is needed to establish a definitive diagnosis.The lack of a specific diagnosis must be explicitly documented.
** This code is intended for use when the imaging findings are nonspecific and further evaluation is required. It is not a substitute for a specific diagnosis.Always consult the official ICD-10-CM coding guidelines for the most current information.
- Payment Status: Active
- Specialties:Gastroenterology, Hepatology, Radiology, Internal Medicine
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, Ambulatory Surgical Center