ICD-10 Coding for Abnormal Ultrasound Findings(O28.3, R93.8)
Complete ICD-10-CM coding and documentation guide for Abnormal Ultrasound Findings. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Ultrasound Findings
O28.0-O28.9Primary Range
Abnormal findings on antenatal screening of the mother
Used for abnormal findings during prenatal ultrasound screenings.
Abnormal findings on diagnostic imaging of other body structures
Used for non-obstetric abnormal findings on imaging 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 |
|---|---|---|---|
| O28.3 | Abnormal ultrasonic finding on antenatal screening of mother | Use when an abnormal finding is detected during routine prenatal ultrasound screening. |
|
| R93.8 | Abnormal findings on diagnostic imaging of other specified body structures | Use for abnormal findings on non-obstetric imaging studies. |
|
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 ultrasound
Essential facts and insights about Abnormal Ultrasound Findings
Primary ICD-10-CM Codes for abnormal ultrasound
Decision Criteria
clinical Criteria
- Abnormal finding on prenatal ultrasound
Applicable To
- Abnormal ultrasound findings during routine prenatal screening
Excludes
- Normal findings (Z36.0)
Clinical Validation Requirements
- Specific abnormal finding documented during antenatal ultrasound
Code-Specific Risks
- Incorrect sequencing with O35 codes
Coding Notes
- Ensure proper sequencing with O35 codes for fetal abnormalities.
R93.8 - Abnormal findings on diagnostic imaging of other specified body structures
Use for abnormal findings on non-obstetric imaging studies.
Applicable To
- Abnormal findings on non-obstetric imaging
Excludes
- Normal findings (Z00.0)
Clinical Validation Requirements
- Specific abnormal finding documented on imaging
Coding Notes
Ensure documentation specifies the anatomical location of the finding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Maternal care for suspected chromosomal abnormality in fetus
O35.1XX0Differential 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 Ultrasound Findings to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code O28.3.
Impact
Clinical: Inaccurate diagnosis and treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Ensure all imaging reports include specific anatomical locations.
Impact
Reimbursement: Incorrect sequencing can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure O35 codes precede O28.3 in the sequence.
Impact
Improper sequencing of codes can lead to audit flags.
Mitigation Strategy
Review coding guidelines for proper sequencing.
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 Ultrasound Findings, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Ultrasound Findings
Use these documentation templates to ensure complete and accurate documentation for Abnormal Ultrasound Findings. These templates include all required elements for proper coding and billing.
OB Follow-Up Ultrasound
Specialty: ObstetricsRequired Elements
- Indication for ultrasound
- Findings with specific measurements
- Impression and recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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