2025 ICD-10-CM code R90
Abnormal findings on diagnostic imaging of the central nervous system.
Medical necessity for the imaging study itself must be established based on the patient's signs, symptoms, and clinical history.The medical necessity for further workup or treatment will depend on the specific abnormal findings and their potential clinical significance.
The clinician is responsible for ordering appropriate diagnostic imaging studies, interpreting the results in the context of the patient's clinical presentation, and determining the need for further investigation or referral to a specialist if a specific diagnosis cannot be made based on the imaging findings alone.Accurate documentation of the findings and the rationale for further management is crucial.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90-R94)
In simple words: A brain scan or other imaging test has shown something unusual, but doctors haven't yet figured out what it means or what's causing it.More tests or follow-up may be needed.
This code signifies nonspecific abnormal findings discovered through various diagnostic imaging techniques of the central nervous system, including computerized axial tomography (CAT scan), magnetic resonance imaging (MRI/NMR), positron emission tomography (PET scan), thermography, ultrasound (echogram), and X-ray examination.It is used when a more specific diagnosis cannot be made, even after all facts have been investigated, or when the abnormality is transient and the cause undetermined.It also applies to provisional diagnoses for patients who didn't return for further investigation, cases referred elsewhere before diagnosis, or when a more precise diagnosis isn't available.It encompasses situations where signs or symptoms at the initial encounter were transient and their causes couldn't be determined.
Example 1: A patient presents with headaches.An MRI of the brain reveals nonspecific white matter changes (R90.82), but no other abnormalities.Further investigation is needed to determine the cause of the white matter changes and their relationship to the headaches., A patient undergoes a CT scan of the head following a minor fall.The scan shows a small, nonspecific area of increased density (R90.89). The finding is deemed clinically insignificant, and no further action is taken., An elderly patient with memory problems has a PET scan of the brain. The scan shows a nonspecific reduction in glucose metabolism (R90.89) but doesn't meet the criteria for a specific diagnosis of dementia.Follow-up cognitive assessments are recommended.
Documentation should include the type of imaging study performed, the specific findings, the interpretation of the findings in the clinical context, and the plan for further investigation or management.If the findings are incidental and not considered clinically significant, this should also be documented.
** This code should not be used for abnormal findings on antenatal screening of the mother (O28.-) or for signs and symptoms classified in the body system chapters.
- Specialties:Radiology, Neurology, Neurosurgery, Internal Medicine, Family Medicine, and any specialty that orders and interprets diagnostic imaging of the central nervous system.
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Independent Clinic, and other settings where diagnostic imaging is performed.