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2025 ICD-10-CM code R90.82

White matter disease, unspecified.

Coding guidelines for ICD-10-CM should be followed.R90.82 should only be used when a more specific diagnosis cannot be assigned.Always use the highest level of specificity possible.

Modifiers do not apply to ICD-10 codes.

Medical necessity is established when the diagnostic imaging is ordered based on clinical suspicion of white matter disease supported by symptoms, signs, or risk factors. The medical necessity for further investigations (e.g., additional imaging, neurological consultation) is determined by the severity of findings, clinical presentation, and need to establish a definitive diagnosis to guide management.

The clinical responsibility includes ordering and interpreting the diagnostic imaging (MRI, CT scan, etc.), conducting a neurological examination to assess the patient's clinical presentation, considering differential diagnoses based on the imaging findings, and initiating further investigations (if necessary) to establish a definitive diagnosis and formulate a treatment plan.

IMPORTANT:Consider using more specific codes if the underlying white matter disease is identified (e.g.,codes for multiple sclerosis, leukodystrophy, etc.).If imaging is normal, consider other codes to reflect the clinical findings.

In simple words: This code means that a doctor found something unusual in the brain's white matter during a test like an MRI or CT scan, but they don't yet know what the problem is.

This code signifies the presence of an unspecified white matter disease detected through diagnostic imaging or other functional studies, without a definitive diagnosis established.It encompasses cases where the findings suggest a white matter abnormality but further investigation is needed to pinpoint a specific condition.

Example 1: A patient presents with progressive gait disturbance and cognitive decline.MRI reveals diffuse white matter hyperintensities.R90.82 is assigned pending further investigations to determine the specific etiology (e.g., vascular dementia, multiple sclerosis)., A patient undergoes a routine brain MRI which reveals subtle white matter changes.The patient is asymptomatic.R90.82 is used for documentation purposes pending further evaluation to rule out any clinically significant condition., An elderly patient with a history of hypertension undergoes a brain MRI showing extensive white matter lesions. Clinical correlation suggests vascular cognitive impairment, but further testing is needed to confirm the diagnosis. R90.82 is assigned temporarily before a definitive diagnosis.

Detailed clinical history, neurological examination findings, and complete radiological reports (including imaging modality, date of scan, and description of abnormalities) are required for accurate coding.If further tests are conducted, their results should also be documented.

** This code is often a temporary placeholder until further diagnostic information leads to a more specific diagnosis.It should not be used if a specific white matter disease has been identified.Proper documentation is crucial for justifying the use of this code.

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