ICD-10 Coding for Renal Dysfunction(N18.1, N18.6)
Complete ICD-10-CM coding and documentation guide for Renal Dysfunction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Renal Dysfunction
N18.1-N18.6Primary Range
Chronic kidney disease stages 1-5 and end-stage renal disease
Primary code range for chronic kidney disease, covering all stages and ESRD.
Type 2 diabetes mellitus with diabetic chronic kidney disease
Used when CKD is caused by diabetes, sequenced before CKD codes.
Hypertensive chronic kidney disease with stage 1 through stage 4 CKD, or unspecified CKD
Used when CKD is caused by hypertension, sequenced before CKD codes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N18.1 | Chronic kidney disease, stage 1 | Use when CKD stage 1 is documented with appropriate GFR and kidney damage evidence. |
|
| N18.6 | End stage renal disease | Use when ESRD is documented, regardless of prior CKD stage. |
|
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 renal dysfunction
Essential facts and insights about Renal Dysfunction
Primary ICD-10-CM Codes for renal dysfunction
Decision Criteria
clinical Criteria
- GFR ≥ 90 with kidney damage
Applicable To
- CKD stage 1
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- GFR ≥ 90 with evidence of kidney damage
Code-Specific Risks
- Misclassification if GFR is not documented
Coding Notes
- Ensure GFR and kidney damage are documented.
N18.6 - End stage renal disease
Use when ESRD is documented, regardless of prior CKD stage.
Applicable To
- ESRD
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- Documented ESRD status
Coding Notes
Always document dialysis status.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dependence on renal dialysis
Z99.2Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Renal Dysfunction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N18.1.
Impact
Clinical: Misleading clinical picture., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always specify 'chronic' when applicable.
Impact
Reimbursement: Reduced reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Poor data quality affecting patient records.
Mitigation Strategy
Always use the most specific CKD stage code available.
Impact
Inadequate documentation of CKD stages can lead to audit issues.
Mitigation Strategy
Ensure all CKD stages are clearly documented with supporting lab results.
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 Dysfunction, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Renal Dysfunction
Use these documentation templates to ensure complete and accurate documentation for Renal Dysfunction. These templates include all required elements for proper coding and billing.
Nephrology Progress Note
Specialty: NephrologyRequired Elements
- Subjective symptoms
- Objective findings
- Assessment with CKD stage
- Plan including treatment and referrals
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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