Q&A: Reporting acute renal insufficiency due to dehydration in ICD-10-CM

Q: Our team is having trouble deciding how to report a recent case. We have a patient who presented with a two-day history of nausea, vomiting, and diarrhea. The patient is showing symptoms of fatigue and dehydration. Lab values show hyperkalemia, acidosis, and elevated serum creatinine and blood urea nitrogen levels. The patient is diagnosed as having acute renal insufficiency due to dehydration with decreased urinary output and was admitted for IV hydration. What diagnosis codes should we assign?

A: The ICD-10-CM codes that would be most appropriate for this case are:

• N28.9, disorder of kidney and ureter, unspecified
• E86.0, dehydration

ICD-10-CM code N28.9 is reported to capture the acute renal insufficiency. Based on your documentation, acute kidney injury/failure (N17.9) cannot be assigned. However, based on the clinical indicators documented, a query should be submitted to the provider to specify if the type of acute renal insufficiency is acute kidney injury/acute renal failure.

Editor’s note: Sarah Humbert, RHIA, AHIMA-certified ICD-10-CM/PCS trainer, coding and compliance manager at KIWI-TEK, LLC, and Temeka Davis, RHIT, coding manager at KIWI-TEK, LLC, answered this question during HCPro’s webinar Acute Kidney Injury and Acute Renal Failure: 2018 Coding, Criteria, and Classifications.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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