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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:

Elevated CreatinineHigh Creatinine Levels

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

CodeDescriptionWhen to UseKey Documentation
R94.4Abnormal results of kidney function studiesUse when creatinine is elevated but no chronic or acute kidney disease is confirmed.
  • Documented abnormal creatinine levels without other kidney disease indicators.
N18.9Chronic kidney disease, unspecifiedUse when CKD is confirmed but not specified.
  • eGFR <60 mL/min/1.73 m² for more than 3 months.
N17.9Acute kidney failure, unspecifiedUse when acute kidney injury is confirmed.
  • Increase in serum creatinine by ≥0.3 mg/dL within 48 hours or 1.5x baseline.

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

The ICD-10 code R94.4 is used for abnormal results of kidney function studies, including isolated elevated creatinine.

Primary ICD-10-CM Codes for abnormal creatinine

Abnormal results of kidney function studies
Billable Code

Decision Criteria

clinical Criteria

  • Elevated creatinine without evidence of CKD or AKI.

Applicable To

  • Isolated elevated creatinine

Excludes

  • Chronic kidney disease (N18.-)
  • Acute kidney failure (N17.-)

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.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Other specified abnormal findings of blood chemistry

R79.89
Use for other abnormal blood chemistry findings alongside elevated creatinine.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Chronic kidney disease, unspecified

N18.9
Use when CKD is confirmed with persistent eGFR <60 for over 3 months.

Acute kidney failure, unspecified

N17.9
Use when creatinine increases by ≥0.3 mg/dL within 48 hours or 1.5x baseline.

Abnormal results of kidney function studies

R94.4
Use R94.4 for isolated abnormal creatinine without CKD.

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: Nephrology

Required Elements

  • Baseline creatinine
  • Current creatinine levels
  • Clinical context and suspected etiology
  • Treatment plan

Example Documentation

Patient presents with Cr 2.4 mg/dL (baseline 0.9), oliguria <400mL/24h, likely due to dehydration.

Examples: Poor vs. Good Documentation

Poor Documentation Example
High creatinine, will monitor.
Good Documentation Example
Cr 2.4 mg/dL (baseline 0.9), oliguria <400mL/24h, FENa 1.2% confirms ATN.
Explanation
The good example provides specific lab values, baseline comparison, and clinical context.

Need help with ICD-10 coding for Abnormal Creatinine? Ask your questions below.

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