ICD-10 Coding for Low Albumin(E88.09, R77.0, E46)
Complete ICD-10-CM coding and documentation guide for Low Albumin. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Low Albumin
E88.0-E88.09Primary Range
Metabolic disorders
Primary range for hypoalbuminemia due to metabolic disorders.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E88.09 | Other disorders of plasma-protein metabolism, not elsewhere classified | Use when hypoalbuminemia is integral to a metabolic disorder. |
|
| R77.0 | Abnormality of albumin | Use for isolated lab findings of low albumin without a known cause. |
|
| E46 | Unspecified protein-calorie malnutrition | Use when hypoalbuminemia is due to malnutrition. |
|
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 low albumin
Essential facts and insights about Low Albumin
Primary ICD-10-CM Codes for low albumin
Decision Criteria
clinical Criteria
- Albumin level <3.5 g/dL with a documented metabolic disorder.
Applicable To
- Hypoalbuminemia due to metabolic disorders
Excludes
- R77.0 (Abnormality of albumin)
Clinical Validation Requirements
- Albumin <3.5 g/dL
- Underlying condition such as liver or kidney disease
Code-Specific Risks
- Incorrectly using when no metabolic disorder is present
Coding Notes
- Ensure documentation links hypoalbuminemia to a specific metabolic disorder.
R77.0 - Abnormality of albumin
Use for isolated lab findings of low albumin without a known cause.
Applicable To
- Isolated low albumin findings
Excludes
- E88.09 (Metabolic disorders)
Clinical Validation Requirements
- Albumin ≤2.9 g/dL
- No underlying metabolic disorder
Coding Notes
Do not use if a metabolic disorder is documented.
E46 - Unspecified protein-calorie malnutrition
Use when hypoalbuminemia is due to malnutrition.
Applicable To
- Malnutrition with low albumin
Clinical Validation Requirements
- Albumin <3.4 g/dL
- Weight loss or BMI <18.5
Coding Notes
Ensure documentation supports malnutrition diagnosis.
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 Low Albumin to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E88.09.
Impact
Clinical: Inaccurate clinical assessment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Always document specific albumin levels.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use E88.09 if hypoalbuminemia is due to a metabolic disorder.
Impact
Using R77.0 when a metabolic disorder is present.
Mitigation Strategy
Ensure thorough documentation of underlying conditions.
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 Low Albumin, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Low Albumin
Use these documentation templates to ensure complete and accurate documentation for Low Albumin. These templates include all required elements for proper coding and billing.
Hospital Progress Note
Specialty: Internal MedicineRequired Elements
- Quantitative albumin value
- Etiologic link
- Clinical correlation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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