2025 ICD-10-CM code R85.8
This code signifies other abnormal findings in specimens obtained from the digestive organs and abdominal cavity.
Medical necessity is established by the need to investigate and understand the abnormal findings. The documentation should support the clinical rationale for ordering the tests and using the code.If further investigation is pending, that should also be clearly documented.
Clinicians, including physicians, physician assistants, and nurse practitioners, are responsible for ordering appropriate tests, interpreting the results, and using this code when no more specific diagnosis can be made after investigation, the symptoms are transient and the cause is undetermined, the diagnosis is provisional and the patient did not return for further investigation, the case was referred elsewhere before diagnosis, a more precise diagnosis is not available for other reasons, or the symptoms themselves represent significant medical problems.
In simple words: This code indicates that lab tests of samples from your digestive system or abdominal area showed something unusual, but doctors don't yet know what caused it or need more tests to understand it better.
This code represents other abnormal findings discovered during the examination of specimens taken from the digestive organs (such as the stomach, intestines, liver, pancreas) and the abdominal cavity (the space containing these organs).It is used when a more specific diagnosis is not available or further investigation is needed.This code excludes abnormal findings on antenatal screening, specific perinatal conditions, symptoms classified in other chapters, breast symptoms, abnormal findings on examination of blood (R70-R79), abnormal findings on examination of urine (R80-R82), and abnormal tumor markers (R97.-).
Example 1: A patient presents with abdominal pain.A peritoneal fluid sample is taken and shows unusual cellular activity, but no specific infection or malignancy can be identified. R85.8 would be used until further testing clarifies the diagnosis., A biopsy of intestinal tissue reveals mild inflammation, but no specific cause can be determined.R85.8 is used until further workup is completed., A patient has an abnormal enzyme level in a stool sample, but further tests are normal. The provider uses R85.8 to document the initial finding.
Documentation should include details of the specimen collected (e.g., peritoneal fluid, stool sample, biopsy tissue), the specific abnormal finding, and the results of any additional tests performed to investigate the abnormality.The reason for using the unspecified code should also be documented (e.g., transient symptoms, pending further investigation).
** It is crucial to follow up with additional testing and investigation to arrive at a more definitive diagnosis whenever possible.
- Specialties:Gastroenterology, General surgery, Internal medicine, Pathology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Independent Clinic, Independent Laboratory