Find information on documenting a history of nephrolithiasis for accurate medical coding and clinical documentation. Learn about relevant ICD-10 codes, past medical history documentation, kidney stone disease history, renal calculi, nephrolithiasis diagnosis, and best practices for healthcare professionals. This resource provides guidance on capturing complete patient history related to nephrolithiasis for optimal patient care and accurate billing.
Also known as
Calculus of kidney and ureter
Covers kidney and ureter stones, including history.
Personal history of medical conditions
Includes history of various medical issues, potentially relevant.
Other disorders of kidney and ureter
May include residual effects or complications related to past stones.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the nephrolithiasis currently active?
Yes
Do NOT code history of nephrolithiasis. Code the active condition (e.g., N20.0, N20.1).
No
Any documented residual effects?
When to use each related code
| Description |
|---|
| History of kidney stones |
| Renal colic |
| Nephrocalcinosis |
Coding for nephrolithiasis requires specifying laterality (right, left, bilateral) when documented. Unspecified laterality leads to coding errors.
If obstruction is present with the history of nephrolithiasis, it requires a separate code. Failing to code obstruction impacts reimbursement and data accuracy.
Discrepancies between physician notes and diagnostic reports regarding nephrolithiasis history create coding ambiguity and potential compliance issues.
Patient presents with a history of nephrolithiasis, also known as kidney stones. The patient reports past episodes of renal colic, characterized by severe flank pain, often radiating to the groin or lower abdomen. Previous stone analysis, if available, indicated (insert stone composition, e.g., calcium oxalate, uric acid, struvite). Review of systems reveals (positive/negative) hematuria, dysuria, and urinary frequency. The patient denies fever, chills, or nausea suggesting no current infection. Physical exam reveals (tenderness/no tenderness) in the costovertebral angle. Assessment includes history of kidney stones with (mention current status e.g., recurrent symptoms, asymptomatic follow-up). Plan includes (mention diagnostic tests if ordered, e.g., urinalysis, kidney ultrasound, CT scan without contrast) to evaluate for current stone presence and assess renal function. Patient education provided on dietary modifications (e.g., increased fluid intake, low-sodium diet), depending on stone composition, to prevent recurrence. Medical coding will consider ICD-10 code N20.0 (Calculus of kidney) and relevant CPT codes for diagnostic testing and procedures. Follow-up scheduled to review diagnostic results and discuss management options, which may include medical expulsive therapy, lithotripsy, or other surgical interventions if indicated.