2025 ICD-10-CM code N18.9
(Active) Effective Date: N/A Revision Date: N/A Renal failure - Chronic kidney disease XIV Diseases of the genitourinary system Feed
Chronic kidney disease, unspecified;This code is used when only chronic kidney disease is documented without specifying the stage.
No specific modifiers are typically used with N18.9, but appropriate modifiers may be used depending on circumstances of service. Consult official coding guidelines for more details.
Medical necessity is established when clinical findings indicate the presence of chronic kidney disease requiring ongoing monitoring and management.The unspecified nature of the code implies that further evaluation is needed to determine the severity and appropriate treatment plan.
Diagnosis and management of chronic kidney disease, including monitoring kidney function, managing associated symptoms, and referring for specialized care when needed.
In simple words: This code means a person has chronic kidney disease, but the doctor hasn't specified how severe it is.It covers various kidney problems that last a long time.
N18.9, Chronic kidney disease, unspecified, encompasses various forms of chronic renal disease without a specified stage of severity.It includes conditions such as chronic renal disease, chronic renal failure not otherwise specified (NOS), chronic renal insufficiency, chronic uremia NOS, and diffuse sclerosing glomerulonephritis NOS.If the stage of chronic kidney disease is known, a more specific code from the N18.1-N18.5 range should be used instead. If both a stage of CKD and ESRD are documented, code N18.6 should be used.
Example 1: A 65-year-old patient with a history of hypertension presents with elevated creatinine levels and reduced glomerular filtration rate (GFR).The physician diagnoses chronic kidney disease, but does not specify the stage due to insufficient data from tests. Code N18.9 is assigned., A 70-year-old patient with type 2 diabetes mellitus is found to have persistent proteinuria and impaired kidney function.Laboratory results indicate chronic kidney disease, but further investigations are needed to determine the precise stage. Code N18.9 is used temporarily., A 45-year-old patient with a family history of kidney disease undergoes routine blood work which reveals abnormalities in kidney function tests, suggestive of chronic kidney disease.Further testing is planned to determine the stage and underlying cause. N18.9 is used until staging is complete.
Medical record should include details regarding the diagnosis of chronic kidney disease, including any clinical findings (e.g., elevated creatinine, reduced GFR, proteinuria, hematuria), relevant laboratory test results, imaging studies if performed, and the physician's assessment of the patient's overall clinical presentation. The absence of stage determination should be explicitly noted.If applicable, document associated conditions like diabetes or hypertension.
** This code should be used cautiously.Efforts should be made to determine the stage of chronic kidney disease to assign a more specific and accurate code.Regular review of patient records and progress notes is crucial to ensure accurate coding over time.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Nephrology, Internal Medicine, Family Medicine
- Place of Service:Office, Hospital, Outpatient