Start New EnglishEspañol中文РусскийالعربيةTiếng ViệtFrançaisDeutsch한국어Tagalog Library Performance
BETA v.3.0

2025 ICD-10-CM code R93.2

Abnormal findings on diagnostic imaging of the liver and biliary tract, such as nonvisualization of the gallbladder.

This code should be used cautiously and only when a specific diagnosis cannot be determined even after all available information has been analyzed.The documentation must clearly reflect this uncertainty.If a specific diagnosis is subsequently determined, that diagnosis should be coded instead of R93.2.

Medical necessity is established by the presence of clinical symptoms or findings warranting the performance of diagnostic imaging to evaluate the liver and biliary tract.The use of code R93.2 is justified when the imaging reveals nonspecific abnormalities that require additional investigation before a specific diagnosis can be determined.

The clinical responsibility involves ordering and interpreting diagnostic imaging studies of the liver and biliary tract, correlating findings with patient history and physical exam, ordering further tests to elucidate the findings, and managing the patient accordingly.

IMPORTANT:Consider other codes within the R93 range (R93.0-R93.8) if imaging reveals abnormalities in other specific body structures. If a specific diagnosis is established following further investigation, a more specific ICD-10-CM code should be assigned.

In simple words: This code means that a doctor found something unusual in images (like X-rays, ultrasounds, or CT scans) of your liver or bile ducts, but they don't yet know what the problem is. More tests may be needed for a proper diagnosis.

This code is used to report nonspecific abnormal findings detected during diagnostic imaging procedures of the liver and biliary tract.These findings lack sufficient detail to assign a more specific diagnosis. Examples include nonvisualization of the gallbladder, unusual liver texture or size, or undefined masses or lesions. The code should only be used when a more definitive diagnosis is not possible even after all relevant investigations. It encompasses cases where the abnormality is transient, the etiology is unknown, or further investigation is pending but not readily available. This code is distinct from findings definitively indicating a specific disease elsewhere classified.

Example 1: A patient presents with vague abdominal pain. An ultrasound reveals an undefined mass in the liver.The physician documents the findings as "abnormal liver findings on ultrasound" pending further investigation (e.g., biopsy, MRI). R93.2 would be coded., During a routine health check-up, an abdominal CT scan shows nonvisualization of the gallbladder. Further testing is indicated to determine the cause. R93.2 would be appropriately assigned., A patient undergoes an MRI for suspected liver disease. The images reveal several indistinct lesions that are not easily characterized.After attempting to clarify with additional testing, a definitive diagnosis cannot be reached. R93.2 would be the best fit.

The medical record must document the imaging study performed (e.g., ultrasound, CT, MRI), detailed descriptions of the abnormal findings, and a clear statement indicating that further diagnostic evaluation is needed to establish a definitive diagnosis.The lack of a specific diagnosis must be explicitly documented.

** This code is intended for use when the imaging findings are nonspecific and further evaluation is required. It is not a substitute for a specific diagnosis.Always consult the official ICD-10-CM coding guidelines for the most current information.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

Discover what matters.

iFrame™ AI's knowledge is aligned with and limited to the materials uploaded by users and should not be interpreted as medical, legal, or any other form of advice by iFrame™.