ICD-10 Coding for Abnormal Creatinine(R94.4, N18.9, N17.9)
Complete ICD-10-CM coding and documentation guide for Abnormal Creatinine. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Creatinine
R94.4Primary Range
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.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R94.4 | Abnormal results of kidney function studies | Use when creatinine is elevated but no chronic or acute kidney disease is confirmed. |
|
| N18.9 | Chronic kidney disease, unspecified | Use when CKD is confirmed but not specified. |
|
| N17.9 | Acute kidney failure, unspecified | Use when acute kidney injury is confirmed. |
|
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 creatinine
Essential facts and insights about Abnormal Creatinine
Primary ICD-10-CM Codes for abnormal creatinine
Decision Criteria
clinical Criteria
- Elevated creatinine without evidence of CKD or AKI.
Applicable To
- Isolated elevated creatinine
Clinical Validation Requirements
- Documented abnormal creatinine levels without other kidney disease indicators.
Code-Specific Risks
- Misclassification if CKD or AKI is present but not documented.
Coding Notes
- Ensure documentation specifies no underlying kidney disease when using R94.4.
N18.9 - Chronic kidney disease, unspecified
Use when CKD is confirmed but not specified.
Applicable To
- Chronic renal failure
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- eGFR <60 mL/min/1.73 m² for more than 3 months.
Coding Notes
Ensure CKD is confirmed with appropriate lab results.
N17.9 - Acute kidney failure, unspecified
Use when acute kidney injury is confirmed.
Applicable To
- Acute renal failure
Excludes
- Chronic kidney disease (N18.-)
Clinical Validation Requirements
- Increase in serum creatinine by ≥0.3 mg/dL within 48 hours or 1.5x baseline.
Coding Notes
Document the cause and context of AKI clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other specified abnormal findings of blood chemistry
R79.89Differential 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 Creatinine to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R94.4.
Impact
Clinical: May lead to misdiagnosis of AKI., Regulatory: Non-compliance with documentation standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Always check previous lab results for baseline., Include baseline in all relevant documentation.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts the accuracy of clinical data.
Mitigation Strategy
Use specific codes like N17.9 for AKI or N18.9 for CKD when criteria are met.
Impact
Coding AKI without meeting clinical criteria.
Mitigation Strategy
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.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Creatinine, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Creatinine
Use these documentation templates to ensure complete and accurate documentation for Abnormal Creatinine. These templates include all required elements for proper coding and billing.
Acute Kidney Injury Documentation
Specialty: NephrologyRequired Elements
- Baseline creatinine
- Current creatinine levels
- Clinical context and suspected etiology
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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