ICD-10 Coding for Renal Insufficiency Unspecified(N28.9)
Complete ICD-10-CM coding and documentation guide for Renal Insufficiency Unspecified. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Renal Insufficiency Unspecified
N28.9Primary Range
Disorder of kidney and ureter, unspecified
Used for unspecified renal insufficiency without documentation of chronicity, stage, or etiology.
Chronic kidney disease, unspecified
Used when 'chronic' is documented but without specific staging.
Acute kidney injury, unspecified
Used for acute kidney injury with sudden onset and significant creatinine rise.
Key Information: ICD-10 code for renal insufficiency unspecified
Essential facts and insights about Renal Insufficiency Unspecified
Primary ICD-10-CM Code for renal insufficiency unspecified
Decision Criteria
documentation Criteria
- Absence of 'chronic' or 'acute' in documentation.
clinical Criteria
- eGFR between 45-59 mL/min without acute or chronic indicators.
Applicable To
- Unspecified renal insufficiency
Clinical Validation Requirements
- Serum creatinine 1.5-2.9 mg/dL
- eGFR 45-59 mL/min
Code-Specific Risks
- Misclassification as chronic or acute without proper documentation.
Coding Notes
- Ensure documentation does not imply chronicity or acute onset unless specified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Renal Insufficiency Unspecified to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N28.9.
Impact
Clinical: May lead to inappropriate treatment or monitoring., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials or incorrect reimbursement.
Mitigation Strategy
Educate providers on the importance of documenting chronicity.
Impact
Reimbursement: Incorrect coding can lead to denied claims or incorrect payment., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of patient records and data reporting.
Mitigation Strategy
Verify documentation for terms like 'chronic' or 'acute' before coding.
Impact
Failure to document chronicity can lead to audit findings.
Mitigation Strategy
Implement regular training sessions for providers on documentation standards.
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 Renal Insufficiency Unspecified, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Renal Insufficiency Unspecified
Use these documentation templates to ensure complete and accurate documentation for Renal Insufficiency Unspecified. These templates include all required elements for proper coding and billing.
Primary Care Assessment
Specialty: NephrologyRequired Elements
- Serum creatinine levels
- eGFR values
- Documentation of symptoms or lack thereof
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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