ICD-10 Coding for Uremic Encephalopathy(N18.9, G93.41)
Complete ICD-10-CM coding and documentation guide for Uremic Encephalopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uremic Encephalopathy
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N18.9 | Chronic kidney disease, unspecified | Use when chronic kidney disease is the underlying cause of uremic encephalopathy. |
|
| G93.41 | Metabolic encephalopathy | Use when encephalopathy is due to metabolic disturbances from uremia. |
|
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 uremic encephalopathy
Essential facts and insights about Uremic Encephalopathy
Primary ICD-10-CM Codes for uremic encephalopathy
Decision Criteria
clinical Criteria
- Presence of chronic kidney disease with neurological symptoms
Applicable To
- Chronic renal failure
Excludes
- Acute kidney failure (N17.-)
Clinical Validation Requirements
- Documentation of chronic kidney disease
- Lab results showing elevated creatinine
Code-Specific Risks
- Incorrectly using for acute kidney failure
Coding Notes
- Always sequence CKD code first followed by encephalopathy code.
G93.41 - Metabolic encephalopathy
Use when encephalopathy is due to metabolic disturbances from uremia.
Applicable To
- Uremic encephalopathy
Excludes
- Hepatic encephalopathy (K76.82)
Clinical Validation Requirements
- Neurological symptoms such as confusion or delirium
- Lab evidence of metabolic imbalance
Coding Notes
Ensure documentation specifies 'uremic' or 'metabolic' to avoid denials.
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 Uremic Encephalopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N18.9.
Impact
Clinical: Inaccurate diagnosis and treatment planning., Regulatory: Non-compliance with coding guidelines., Financial: Potential for claim denials and reduced reimbursement.
Mitigation Strategy
Educate providers on documentation requirements., Implement checklist for encephalopathy documentation.
Impact
Reimbursement: Potential for reduced reimbursement due to lack of specificity., Compliance: Increased risk of audit due to unspecified coding., Data Quality: Decreased accuracy in clinical data reporting.
Mitigation Strategy
Ensure documentation specifies 'uremic' or 'metabolic' encephalopathy.
Impact
Risk of audit if encephalopathy type is not specified.
Mitigation Strategy
Ensure all documentation includes specific type of encephalopathy.
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 Uremic Encephalopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uremic Encephalopathy
Use these documentation templates to ensure complete and accurate documentation for Uremic Encephalopathy. These templates include all required elements for proper coding and billing.
Patient with ESRD presenting with confusion
Specialty: NephrologyRequired Elements
- Diagnosis of uremic encephalopathy
- Lab results (BUN, creatinine)
- Neurological symptoms
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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