ICD-10 Coding for Uremia(N18.6, R39.2)
Complete ICD-10-CM coding and documentation guide for Uremia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uremia
N18.1-N18.6Primary Range
Chronic kidney disease (CKD) stages
Primary codes for CKD stages, necessary for coding uremic conditions related to CKD.
Dependence on renal dialysis
Ancillary code for patients on dialysis, often used with 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 |
|---|---|---|---|
| N18.6 | End stage renal disease | Use when documenting ESRD with uremic manifestations. |
|
| R39.2 | Extrarenal uremia | Use for uremia due to prerenal causes, not related to CKD. |
|
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: How to code uremic encephalopathy?
Essential facts and insights about Uremia
Primary ICD-10-CM Codes for uremia
Decision Criteria
clinical Criteria
- Presence of ESRD with uremic symptoms.
Applicable To
- Uremic syndrome in ESRD
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- GFR < 15 mL/min
- Elevated BUN and creatinine levels
Code-Specific Risks
- Incorrectly using without specifying uremic manifestations.
Coding Notes
- Ensure CKD stage is documented before using uremic manifestation codes.
R39.2 - Extrarenal uremia
Use for uremia due to prerenal causes, not related to CKD.
Applicable To
- Prerenal uremia
Excludes
- Uremia NOS (N19)
Clinical Validation Requirements
- Evidence of prerenal causes such as dehydration.
Coding Notes
Ensure documentation specifies prerenal cause.
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 Uremia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N18.6.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Potential audit issues., Financial: Incorrect reimbursement.
Mitigation Strategy
Always document CKD stage., Use specific manifestation codes.
Impact
Reimbursement: Incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use N18.x with appropriate manifestation codes.
Impact
Failure to document CKD stage can lead to audit flags.
Mitigation Strategy
Implement mandatory CKD stage documentation in EHR.
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 Uremia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uremia
Use these documentation templates to ensure complete and accurate documentation for Uremia. These templates include all required elements for proper coding and billing.
Uremic encephalopathy in ESRD
Specialty: NephrologyRequired Elements
- Patient symptoms
- Lab results
- CKD stage
- Dialysis status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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