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2025 ICD-10-CM code N28.9

Unspecified disorder of the kidney and ureter.

This code should only be used when a more precise diagnosis is unavailable after a thorough clinical evaluation.It should not be used to circumvent proper code assignment in cases where a more specific code is available.Always query the physician if the clinical documentation is insufficient to identify the underlying cause.

Medical necessity for this code hinges on the clinical presentation and diagnostic findings. The necessity stems from a need to establish the cause of renal or ureteral dysfunction that warrants further investigation, regardless of whether the patient exhibits symptomatic complaints.If no further investigation is deemed necessary, this code might not meet medical necessity criteria. The treating physician must thoroughly document the rationale for selecting this code in these situations.

The clinical responsibility depends heavily on the underlying cause of the unspecified renal or ureteric disorder.This might involve nephrologists, urologists, or other specialists depending on the specific clinical presentation and patient history.The physician must conduct a thorough investigation to determine the cause and to select the best treatment option.

IMPORTANT:Consider more specific codes if the underlying condition is known (e.g., N17 for acute kidney injury, N18 for chronic kidney disease).If the disorder is related to a specific infectious or parasitic disease, use the appropriate code from Chapter 1 (A00-B99).If due to a neoplasm (C00-D49) or other specified condition, use those corresponding codes.

In simple words: This code means there's a problem with one or both kidneys or the tubes that carry urine from the kidneys to the bladder (ureters), but the exact problem isn't known or specified.

This code represents a nonspecific disorder affecting the kidney or ureter.It is used when a more precise diagnosis is not possible or documented.The kidneys filter blood to produce urine, which is then transported to the bladder via the ureters.This code encompasses a broad range of potential issues within these structures, excluding those with more specific classifications (such as those involving urolithiasis, congenital malformations, infections, or neoplasms).

Example 1: A 65-year-old male presents with vague abdominal discomfort and elevated creatinine levels.Further investigation reveals no clear cause for the renal dysfunction, thus necessitating the use of N28.9., A 30-year-old female reports intermittent flank pain and is found to have mild hydronephrosis without any demonstrable obstruction or infection.After a comprehensive evaluation, N28.9 is chosen to reflect the unexplained ureteric issue., A 70-year-old patient admitted for unrelated reasons shows slightly elevated blood urea nitrogen (BUN) and creatinine on routine labs. No obvious underlying disease is found and no symptoms are present, so the physician selects N28.9.

Complete history and physical examination, detailed laboratory results (including BUN, creatinine, electrolytes, urinalysis), imaging studies (such as ultrasound, CT scan, or IVP) if performed, and any other relevant diagnostic tests.

** This code is frequently used when imaging studies are normal or non-specific and further investigation does not reveal a conclusive diagnosis.Consider using additional codes for comorbidities or related conditions, as appropriate.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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