Objective To explore the clinical value of contrast-enhanced ultrasound liver imaging reporting and data system (CEUS LI-RADS) in the diagnosis of properties of focal liver lesions (FLLs) with diameter≤3 cm. Methods 82 patients with FLLs from July 2019 to November 2022 were selected as the study subjects. All patients underwent conventional ultrasound and contrast-enhanced ultrasound. Taking pathological examination result as the reference standard, the diagnostic value of CEUS LI-RADS and conventional ultrasound on benign and malignant FLLs was analyzed, and the diagnostic accuracy rate of CEUS LI-RADS on FLLs with different diameters was compared. Results Pathological examination showed that there were 3 cases of benign lesions (2 cases f atypical liver solitary fibrous tumors, 1 case of hepatic hemangioma) and 79 cases of malignant lesions [40 cases of hepatocellular carcinoma (HCC), 14 cases of cholangiocarcinoma, 23 cases of metastatic carcinoma, 1 case of pleomorphic rhabdomyosarcoma, 1 case of epithelioid angiosarcoma). The accuracy rate of LI-RADS in diagnosing FLLs was 90.24% (74/82). The consistency of CEUS LI-RADS with pathological examination result (kappa=0.553) was higher than that of conventional ultrasound (Kappa=0.266). The AUC of CEUS LI-RADS in the diagnosis of benign and malignant liver lesions was greater than that of conventional ultrasound (P<0.05). The accuracy rates of CEUS LI-RADS in the diagnosis of FLLs with diameters of 2-3cm, 1-2cm and <1cm were 94.74% (36/38), 91.18% (31/34) and 70.00% (7/10) respectively. The accuracy rate of CEUS LI-RADS in the diagnosis of FLLs with diameter of 2-3cm was higher than that in the diagnosis of FLLs with diameter< 1cm (χ₂⁼5.191, P=0.023). Conclusion CEUS LI-RADS can be used to judge the malignant probability of FLLs, and LI-RADS LR-5 has diagnostic value on malignant FLLs.