Complete ICD-10-CM coding and documentation guide for Abnormal Creatinine. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Complete code families applicable to Abnormal Creatinine
Abnormal results of kidney function studies
Used for isolated abnormal creatinine without confirmed chronic kidney disease.
Chronic kidney disease, unspecified
Used when chronic kidney disease is confirmed but not specified.
Acute kidney failure, unspecified
Used for acute kidney injury when creatinine increases significantly over a short period.
Compare key differences between these codes to ensure accurate selection
Code | Description | When to Use | Key Documentation |
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R94.4 | Abnormal results of kidney function studies | Use when creatinine is elevated but no chronic or acute kidney disease is confirmed. |
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N18.9 | Chronic kidney disease, unspecified | Use when CKD is confirmed but not specified. |
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N17.9 | Acute kidney failure, unspecified | Use when acute kidney injury is confirmed. |
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Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Essential facts and insights about Abnormal Creatinine
Use when CKD is confirmed but not specified.
Ensure CKD is confirmed with appropriate lab results.
Use when acute kidney injury is confirmed.
Document the cause and context of AKI clearly.
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other specified abnormal findings of blood chemistry
R79.89Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Avoid these common documentation and coding issues when documenting Abnormal Creatinine to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R94.4.
Clinical: May lead to misdiagnosis of AKI., Regulatory: Non-compliance with documentation standards., Financial: Potential for incorrect billing and reimbursement.
Always check previous lab results for baseline., Include baseline in all relevant documentation.
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts the accuracy of clinical data.
Use specific codes like N17.9 for AKI or N18.9 for CKD when criteria are met.
Coding AKI without meeting clinical criteria.
Ensure documentation of creatinine changes and clinical context.
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.
Common questions about ICD-10 coding for Abnormal Creatinine, with expert answers to help guide accurate code selection and documentation.
Use these documentation templates to ensure complete and accurate documentation for Abnormal Creatinine. These templates include all required elements for proper coding and billing.
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