ICD-10 Coding for Abnormal Magnetic Resonance Imaging(R94.02, R90.89)
Complete ICD-10-CM coding and documentation guide for Abnormal Magnetic Resonance Imaging. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Magnetic Resonance Imaging
R90-R94Primary Range
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
This range includes codes for abnormal findings on MRI scans, which are not yet diagnosed.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R94.02 | Abnormal brain scan, other and unspecified | Use when MRI shows abnormal findings in the brain without a specific diagnosis. |
|
| R90.89 | Other abnormal findings on diagnostic imaging of central nervous system | Use for non-lesional CNS findings such as white matter changes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal brain MRI
Essential facts and insights about Abnormal Magnetic Resonance Imaging
Primary ICD-10-CM Codes for abnormal magnetic resonance imaging
Decision Criteria
clinical Criteria
- Presence of abnormal MRI findings without a specific diagnosis.
Applicable To
- Abnormal findings on brain MRI
Excludes
- Specific diagnoses such as Alzheimer's (G30.9)
Clinical Validation Requirements
- Abnormal signal intensity in specific brain regions
Code-Specific Risks
- Risk of using this code when a more specific diagnosis is available.
Coding Notes
- Ensure documentation specifies the abnormal findings clearly.
R90.89 - Other abnormal findings on diagnostic imaging of central nervous system
Use for non-lesional CNS findings such as white matter changes.
Applicable To
- White matter hyperintensities
- Diffuse cortical atrophy
Excludes
- Focal lesions (use R93.0)
Clinical Validation Requirements
- Documentation of white matter hyperintensities or diffuse cortical atrophy
Coding Notes
Ensure findings are clearly documented as non-lesional.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Magnetic Resonance Imaging to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R94.02.
Impact
Clinical: Leads to misinterpretation of patient condition., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.
Mitigation Strategy
Use specific language in reports, Include all relevant measurements
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate health records.
Mitigation Strategy
Use Z09 for follow-up examination after treatment.
Impact
Using R94.02 for specific diagnoses can trigger audits.
Mitigation Strategy
Ensure specific diagnoses are coded with appropriate codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Magnetic Resonance Imaging, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Magnetic Resonance Imaging
Use these documentation templates to ensure complete and accurate documentation for Abnormal Magnetic Resonance Imaging. These templates include all required elements for proper coding and billing.
MRI Report for Abnormal Findings
Specialty: RadiologyRequired Elements
- Clinical Indication
- Technique
- Findings
- Impression
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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