ICD-10 Coding for History of Nephrectomy(Z90.5, Z52.4)
Complete ICD-10-CM coding and documentation guide for History of Nephrectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Nephrectomy
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z90.5 | Acquired absence of kidney | Use when documenting a patient's history of nephrectomy without a transplant. |
|
| Z52.4 | Donor of kidney | Use for patients who have donated a kidney. |
|
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 history of nephrectomy
Essential facts and insights about History of Nephrectomy
Primary ICD-10-CM Codes for history of nephrectomy
Decision Criteria
clinical Criteria
- Patient has undergone nephrectomy without subsequent transplant.
Applicable To
- History of nephrectomy
Excludes
- Z94.0 (Transplanted kidney)
Clinical Validation Requirements
- Operative report confirming nephrectomy
- Imaging showing solitary kidney
Code-Specific Risks
- Incorrectly using Z94.0 for non-transplant cases
Coding Notes
- Ensure documentation specifies laterality and reason for nephrectomy.
Z52.4 - Donor of kidney
Use for patients who have donated a kidney.
Applicable To
- History of kidney donation
Excludes
- Z90.5 (Acquired absence of kidney)
Clinical Validation Requirements
- Donor consent forms
- Transplant program documentation
Coding Notes
Ensure documentation includes donor status and post-donation renal function.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chronic kidney disease, unspecified
N18.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Nephrectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.5.
Impact
Clinical: Inadequate clinical history., Regulatory: Potential audit issues., Financial: Incorrect DRG assignment.
Mitigation Strategy
Use standardized templates., Regular training for documentation staff.
Impact
Reimbursement: Incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify if the nephrectomy was for donation or other reasons.
Impact
Incorrect use of transplant codes for non-transplant nephrectomy.
Mitigation Strategy
Regular audits and staff training.
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 History of Nephrectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Nephrectomy
Use these documentation templates to ensure complete and accurate documentation for History of Nephrectomy. These templates include all required elements for proper coding and billing.
Post-nephrectomy follow-up
Specialty: UrologyRequired Elements
- Procedure date
- Laterality
- Reason for nephrectomy
- Current renal function
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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