2025 ICD-10-CM code R97
(Active) Effective Date: N/A Revision Date: N/A Laboratory findings - Abnormal tumor markers Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Abnormal tumor markers indicate elevated levels of tumor-associated antigens (TAA) or tumor-specific antigens (TSA).
Modifiers may apply depending on the circumstances of the testing and any subsequent procedures. Consult the latest NCCI guidelines.
Medical necessity is established by the physician's clinical judgement based on the patient's symptoms, risk factors, and medical history warranting evaluation for the presence of malignancy.Abnormal tumor marker testing alone is typically not sufficient to establish medical necessity but may be a part of a broader diagnostic work-up.
Laboratory personnel initially identify the abnormal results. Physicians then interpret the results in context of the patient's clinical presentation and order further investigations if necessary.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R97-R97.8
In simple words: This code means that a blood test showed unusual levels of substances that may be linked to cancer.More tests are usually needed to find out if there's actually cancer.
ICD-10-CM code R97, Abnormal tumor markers, encompasses the detection of elevated levels of tumor-associated antigens (TAA) or tumor-specific antigens (TSA) in laboratory tests.This code is used when abnormal levels are found but a definitive diagnosis of a specific malignancy is not yet established.Further investigation is usually required to determine the underlying cause of the abnormal findings. The code is not for reimbursement purposes because more specific codes exist for elevated levels of particular tumor markers.
Example 1: A 55-year-old male patient with a family history of colon cancer undergoes a routine blood test.The test reveals elevated levels of carcinoembryonic antigen (CEA), prompting further investigation with colonoscopy and imaging., A 40-year-old female patient with abdominal pain and bloating undergoes a CA-125 blood test as part of a gynecological evaluation.Elevated CA-125 levels lead to a transvaginal ultrasound and subsequent referral to a gynecologic oncologist., A 60-year-old male patient presents with unexplained weight loss and fatigue.Elevated PSA prompts a prostate biopsy and further oncological work-up.
* Complete laboratory reports detailing the specific tumor markers tested and their quantitative results.* Physician's notes documenting the clinical indication for the tumor marker testing.* Documentation of any further investigations undertaken based on the abnormal tumor marker results.
** R97 should be used cautiously and only when other, more specific codes are not applicable.It is essential to always use the most specific code possible for accurate billing and data analysis.
- Payment Status: Inactive for direct reimbursement
- Modifier TC rule: Not applicable.
- Specialties:Oncology, Hematology, Pathology, Urology, Gynecology
- Place of Service:Office, Hospital, Laboratory