ICD-10 Coding for Abnormal Renal Function(N18.1, N18.6, R94.4)
Complete ICD-10-CM coding and documentation guide for Abnormal Renal Function. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Renal Function
N18.1-N18.6Primary Range
Chronic Kidney Disease (CKD) stages 1-5 and ESRD
Primary range for coding chronic kidney disease stages and end-stage renal disease.
Abnormal results of kidney function studies
Used for abnormal kidney function tests without a confirmed CKD diagnosis.
Acute Kidney Injury, unspecified
Used for acute kidney injury when chronicity is not established.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N18.1 | Chronic kidney disease, stage 1 | Use when CKD stage 1 is documented with eGFR ≥90 and evidence of kidney damage. |
|
| N18.6 | End stage renal disease | Use when ESRD is documented or patient is on dialysis. |
|
| R94.4 | Abnormal results of kidney function studies | Use when abnormal kidney function tests are present without a CKD diagnosis. |
|
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: When to use R94.4 vs N18 codes?
Essential facts and insights about Abnormal Renal Function
Primary ICD-10-CM Codes for abnormal renal function
Decision Criteria
clinical Criteria
- eGFR ≥90 with kidney damage
Applicable To
- CKD stage 1
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- eGFR ≥90 with evidence of kidney damage
Code-Specific Risks
- Misclassification if eGFR is not persistently ≥90.
Coding Notes
- Ensure documentation specifies CKD stage and evidence of kidney damage.
N18.6 - End stage renal disease
Use when ESRD is documented or patient is on dialysis.
Applicable To
- ESRD
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- eGFR <15 or dialysis dependence
Coding Notes
Document dialysis status clearly.
R94.4 - Abnormal results of kidney function studies
Use when abnormal kidney function tests are present without a CKD diagnosis.
Applicable To
- Abnormal kidney function tests
Excludes
- Chronic kidney disease (N18.-)
Clinical Validation Requirements
- Abnormal eGFR or creatinine without CKD diagnosis
Coding Notes
Do not use as primary code if CKD is diagnosed.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Abnormal results of kidney function studies
R94.4Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Renal Function to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N18.1.
Impact
Clinical: Leads to inadequate patient management., Regulatory: Non-compliance with coding standards., Financial: Potential revenue loss due to incorrect coding.
Mitigation Strategy
Always specify CKD stage., Use eGFR values to guide documentation.
Impact
Reimbursement: Incorrect DRG assignment and potential revenue loss., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Query provider for specific CKD stage and use appropriate code.
Impact
Reimbursement: Incorrect risk adjustment factor calculation., Compliance: Violation of ICD-10 coding rules., Data Quality: Confusion in patient records.
Mitigation Strategy
Use N18.6 alone for ESRD.
Impact
Incorrect CKD stage documentation leading to audit flags.
Mitigation Strategy
Ensure accurate and consistent documentation of eGFR and CKD stage.
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 Renal Function, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Renal Function
Use these documentation templates to ensure complete and accurate documentation for Abnormal Renal Function. These templates include all required elements for proper coding and billing.
Nephrology Progress Note
Specialty: NephrologyRequired Elements
- CKD stage
- eGFR values
- Underlying cause
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Discharge Summary
Specialty: Internal MedicineRequired Elements
- Final diagnoses
- Follow-up plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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