ICD-10 Coding for Retroperitoneal Fibrosis(K68.2, N13.5)
Complete ICD-10-CM coding and documentation guide for Retroperitoneal Fibrosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Retroperitoneal Fibrosis
K68-K68.2Primary Range
Disorders of retroperitoneum
This range includes retroperitoneal fibrosis and related disorders.
Obstructive and reflux uropathy
Includes ureteral obstruction associated with retroperitoneal fibrosis.
Secondary malignant neoplasm of retroperitoneum
Used when retroperitoneal fibrosis is due to a secondary malignant neoplasm.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K68.2 | Retroperitoneal fibrosis | Use when retroperitoneal fibrosis is confirmed by imaging and biopsy, and no malignancy is present. |
|
| N13.5 | Crossing vessel and stricture of ureter without hydronephrosis | Use when ureteral obstruction is documented in conjunction with retroperitoneal fibrosis. |
|
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 retroperitoneal fibrosis
Essential facts and insights about Retroperitoneal Fibrosis
Primary ICD-10-CM Codes for retroperitoneal fibrosis
Decision Criteria
clinical Criteria
- Imaging shows periaortic soft tissue mass
documentation Criteria
- Biopsy confirms fibrosis without malignancy
Applicable To
- Idiopathic retroperitoneal fibrosis
- Ormond's disease
Excludes
- Secondary malignant neoplasm of retroperitoneum (C78.6)
Clinical Validation Requirements
- Imaging evidence of retroperitoneal soft tissue mass
- Biopsy ruling out malignancy
- Elevated ESR or CRP
Code-Specific Risks
- Incorrectly coding as malignant neoplasm
- Omitting associated ureteral obstruction
Coding Notes
- Ensure imaging and biopsy documentation are present to support coding.
N13.5 - Crossing vessel and stricture of ureter without hydronephrosis
Use when ureteral obstruction is documented in conjunction with retroperitoneal fibrosis.
Applicable To
- Ureteral obstruction due to retroperitoneal fibrosis
Clinical Validation Requirements
- Imaging showing ureteral obstruction
- Clinical correlation with retroperitoneal fibrosis
Coding Notes
Ensure obstruction is linked to fibrosis in documentation.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Crossing vessel and stricture of ureter without hydronephrosis
N13.5Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Secondary malignant neoplasm of retroperitoneum
C78.6Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Retroperitoneal Fibrosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K68.2.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential denial of claims.
Mitigation Strategy
Ensure detailed imaging reports are included., Specify mass characteristics and effects.
Impact
Reimbursement: Incorrect sequencing can affect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code I71.4 (AAA) first, then K68.2
Impact
Reimbursement: Potential loss of reimbursement for procedures., Compliance: Failure to document complete clinical picture., Data Quality: Incomplete data on patient condition.
Mitigation Strategy
Always link ureteral intervention to obstruction
Impact
Failure to sequence codes correctly can lead to audit flags.
Mitigation Strategy
Regular training on coding guidelines and updates.
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 Retroperitoneal Fibrosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Retroperitoneal Fibrosis
Use these documentation templates to ensure complete and accurate documentation for Retroperitoneal Fibrosis. These templates include all required elements for proper coding and billing.
Radiology Report for Retroperitoneal Fibrosis
Specialty: RadiologyRequired Elements
- Imaging findings
- Soft tissue measurements
- Ureteral involvement
- Impression
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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