2025 ICD-10-CM code R90.89
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90-R94) 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Other abnormal findings on diagnostic imaging of central nervous system.
Medical necessity for using R90.89 is established when an abnormal finding is detected on diagnostic imaging of the central nervous system, but a definitive diagnosis cannot be made based on the available information. The documentation should support the need for the imaging study and the uncertainty surrounding the abnormal finding.
The clinician's responsibility includes ordering appropriate diagnostic imaging studies, interpreting the results in conjunction with a radiologist, correlating the findings with the patient's clinical presentation, and determining the need for further investigation or treatment based on the identified abnormality.
- 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: The imaging scans of your central nervous system (brain and spinal cord) show something unusual, but the doctors haven't yet figured out exactly what it is.
This code signifies other abnormal findings on diagnostic imaging of the central nervous system, encompassing unspecified abnormalities detected through various imaging techniques like MRI, CT, or ultrasound.
Example 1: A patient presents with persistent headaches. An MRI of the brain is performed, revealing an area of increased signal intensity in the white matter that does not have a definitive diagnosis. R90.89 is used to document this finding., During a routine check-up, a CT scan of the head incidentally shows a small calcification in the pineal gland. The finding is non-specific and does not correlate with any current symptoms or known condition. R90.89 can be used to code this., Following a minor fall, a patient undergoes a spinal X-ray which demonstrates a slight asymmetry in the vertebral alignment. However, there is no evidence of fracture or dislocation. The radiologist notes the asymmetry as a non-specific finding, warranting further clinical evaluation. In this situation R90.89 can be applied.
Documentation should include the type of diagnostic imaging performed (e.g., MRI, CT, ultrasound), the location and description of the abnormal finding, and the interpretation by a qualified radiologist. Any associated signs, symptoms, or relevant clinical history should also be documented.
- Specialties:Neurology, Neurosurgery, Radiology, Internal Medicine, Family Medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Independent Clinic, Other Place of Service