ICD-10 Coding for Prerenal Azotemia(R39.2, N17.9)
Complete ICD-10-CM coding and documentation guide for Prerenal Azotemia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Prerenal Azotemia
R39-R39.2Primary Range
Symptoms and signs involving the urinary system
This range includes codes for prerenal azotemia, which is primarily coded as R39.2.
Acute kidney failure and chronic kidney disease
This range includes codes for acute kidney injury (AKI), which may be relevant if prerenal azotemia progresses to AKI.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R39.2 | Extrarenal azotemia | Use when prerenal azotemia is documented with supporting clinical indicators. |
|
| N17.9 | Acute kidney failure, unspecified | Use when acute kidney injury is documented and 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 prerenal azotemia
Essential facts and insights about Prerenal Azotemia
Primary ICD-10-CM Codes for prerenal azotemia
Decision Criteria
clinical Criteria
- BUN/Cr ratio >20:1 and FENa <1%
coding Criteria
- Documented prerenal azotemia with underlying cause
documentation Criteria
- Explicit mention of prerenal azotemia and clinical indicators
Applicable To
- Prerenal azotemia
Excludes
- Acute kidney failure (N17.9)
Clinical Validation Requirements
- BUN/Cr ratio >20:1
- FENa <1%
- Urine osmolality >500 mOsm/kg
Code-Specific Risks
- Confusion with acute kidney injury if not properly documented.
Coding Notes
- Ensure documentation of clinical indicators and underlying cause for accurate coding.
N17.9 - Acute kidney failure, unspecified
Use when acute kidney injury is documented and confirmed.
Applicable To
- Acute renal failure
Excludes
- Chronic kidney disease (N18.-)
Clinical Validation Requirements
- Creatinine rise by 0.3 mg/dL within 48 hours
- Presence of granular casts
Coding Notes
Ensure differentiation from prerenal azotemia based on clinical improvement and lab findings.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Prerenal Azotemia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R39.2.
Impact
Clinical: Misleading clinical picture., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing.
Mitigation Strategy
Always link azotemia to a documented cause., Review clinical notes for completeness.
Impact
Reimbursement: Incorrect DRG assignment leading to potential revenue loss., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Query for clarification and use N17.9 if tubular necrosis is confirmed.
Impact
Improper sequencing of primary and secondary codes.
Mitigation Strategy
Educate coders on correct sequencing rules.
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 Prerenal Azotemia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Prerenal Azotemia
Use these documentation templates to ensure complete and accurate documentation for Prerenal Azotemia. These templates include all required elements for proper coding and billing.
Prerenal azotemia due to dehydration
Specialty: NephrologyRequired Elements
- BUN/Cr ratio
- FENa
- Underlying cause
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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