2025 ICD-10-CM code R82
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Other and unspecified abnormal findings in urine XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Feed
Other and unspecified abnormal findings in urine.
Medical necessity is established by the presence of clinically significant abnormal findings in the urine requiring further investigation to determine the underlying cause.The necessity for additional testing and clinical management will determine the appropriate level of billing.
The clinical responsibility for this code falls upon the physician or healthcare provider who performs and interprets the urinalysis.They are responsible for ordering further investigations if needed and establishing a definitive diagnosis based on the results.
- XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- R80-R82 Abnormal findings on examination of urine, without diagnosis
In simple words: This code is used when a urine test shows something unusual, but doctors don't know exactly what's causing it.It means more tests might be needed to find out what's wrong.
This ICD-10-CM code classifies other and unspecified abnormal findings in urine that cannot be categorized elsewhere.It encompasses various abnormal components detected in urinalysis without a definitive diagnosis.This includes situations where the abnormal findings may point to multiple possible conditions or where further investigation is necessary to establish a specific diagnosis.The code should be used when a more precise diagnosis is not available after thorough investigation or when transient symptoms with undetermined causes are present.
Example 1: A patient presents with general malaise and is found to have protein in their urine (proteinuria) during a routine checkup.Further investigation is needed to determine the cause.R82 would be used in the interim., A patient presents with symptoms suggestive of a urinary tract infection (UTI), but urine culture reveals no bacterial growth. The urinalysis reveals abnormal levels of certain substances of unknown origin. R82 would be the appropriate code., A patient underwent a routine urinalysis as part of a pre-operative assessment. The urinalysis revealed abnormal results, but further tests are required to determine the cause. The R82 code is used while awaiting those results.
Detailed documentation should include the results of the urinalysis, specifying the abnormal findings.Any additional tests performed to investigate the cause, along with their results, should be thoroughly documented.The physician's assessment, including any differential diagnoses considered, should also be recorded.
** The R82 code is a residual code used when other more specific codes are unavailable.Clinicians should always strive to use the most specific code possible based on the available clinical information.
- Payment Status: Active
- Specialties:Urology, Nephrology, Internal Medicine, Family Medicine
- Place of Service:Office, Hospital (inpatient and outpatient), Urgent Care, other clinical settings where urinalysis is performed