ICD-10 Coding for Abnormal Neck Ultrasound(R22.1, R94.6)
Complete ICD-10-CM coding and documentation guide for Abnormal Neck Ultrasound. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Neck Ultrasound
R22-R23Primary Range
Localized swelling, mass and lump of skin and subcutaneous tissue
This range includes codes for neck masses and lumps identified on ultrasound.
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
This range covers abnormal imaging findings, including those related to thyroid studies.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R22.1 | Localized swelling, mass and lump, neck | Use when a neck mass is identified on ultrasound without a confirmed diagnosis. |
|
| R94.6 | Abnormal results of thyroid function studies | Use when thyroid function tests are abnormal and correlate with ultrasound findings. |
|
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 neck ultrasound
Essential facts and insights about Abnormal Neck Ultrasound
Primary ICD-10-CM Codes for abnormal neck ultrasound
Decision Criteria
clinical Criteria
- Presence of a palpable mass in the neck region
Applicable To
- Palpable neck mass
Excludes
- Thyroid mass (E04.1)
Clinical Validation Requirements
- Ultrasound showing a mass in the neck region
- Measurement of the mass in centimeters
Code-Specific Risks
- Risk of undercoding if not specifying the mass location
Coding Notes
- Ensure to document the size and specific location of the neck mass.
R94.6 - Abnormal results of thyroid function studies
Use when thyroid function tests are abnormal and correlate with ultrasound findings.
Applicable To
- Abnormal TSH levels
Excludes
- Thyroiditis (E06.-)
Clinical Validation Requirements
- Abnormal TSH or T4 levels
- Ultrasound findings of thyroid abnormalities
Coding Notes
Document specific thyroid function test results to support this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Neck Ultrasound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R22.1.
Impact
Clinical: May lead to incorrect diagnosis, Regulatory: Non-compliance with coding guidelines, Financial: Potential claim denials
Mitigation Strategy
Always include TSH and T4 levels in the report, Cross-reference lab results with ultrasound findings
Impact
Reimbursement: May lead to lower reimbursement rates, Compliance: Non-compliance with specificity requirements, Data Quality: Decreases accuracy of clinical data
Mitigation Strategy
Use R22.1 when the mass is specifically located in the neck.
Impact
High denial rates for claims without documented TSH/T4 levels.
Mitigation Strategy
Include all relevant lab results in the documentation.
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 Neck Ultrasound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Neck Ultrasound
Use these documentation templates to ensure complete and accurate documentation for Abnormal Neck Ultrasound. These templates include all required elements for proper coding and billing.
Thyroid Nodule Evaluation
Specialty: RadiologyRequired Elements
- Indication for ultrasound
- Technique used
- Findings with measurements
- Impression and recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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