Facebook tracking pixelHypoalbuminemia - AI-Powered ICD-10 Documentation
R77.0
ICD-10-CM
Hypoalbuminemia

Understanding hypoalbuminemia diagnosis, causes, and treatment is crucial for accurate clinical documentation and medical coding. This resource provides information on serum albumin levels, hypoalbuminemia symptoms, ICD-10 codes for hypoalbuminemia, differential diagnosis of low albumin, and lab tests for albumin. Learn about the connection between hypoalbuminemia and edema, liver disease, kidney disease, malnutrition, and nephrotic syndrome. Explore treatment options and best practices for documenting hypoalbuminemia in healthcare settings.

Also known as

Low albumin levels
Albumin deficiency

Diagnosis Snapshot

Key Facts
  • Definition : Low blood albumin levels, a key protein.
  • Clinical Signs : Swelling (edema), fatigue, muscle weakness.
  • Common Settings : Hospitalized patients, malnutrition, liver disease.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R77.0 Coding
E88.8

Disorders of plasma protein metabolism

Includes hypoalbuminemia not due to dietary deficiency.

E40-E46

Malnutrition

May include hypoalbuminemia due to severe protein deficiency.

R64

Cachexia

Often associated with hypoalbuminemia due to underlying illness.

K70-K77

Diseases of liver

Liver disease can cause hypoalbuminemia due to reduced synthesis.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the hypoalbuminemia due to a dietary cause?

  • Yes

    Code E46.0 Malnutrition of moderate degree

  • No

    Is it due to protein-losing enteropathy?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Low blood albumin levels.
Malnutrition, protein deficiency.
Liver cirrhosis, impaired synthesis.

Documentation Best Practices

Documentation Checklist
  • Document serum albumin level <3.5 g/dL
  • Specify cause of hypoalbuminemia (e.g., malnutrition, liver disease)
  • Document related signs/symptoms (e.g., edema, ascites)
  • Include relevant lab results (e.g., liver function tests, urinalysis)
  • Note treatment plan and patient education provided

Coding and Audit Risks

Common Risks
  • Unspecified Etiology

    Coding hypoalbuminemia without documenting the underlying cause leads to inaccurate coding and potential DRG misassignment.

  • Conflicting Documentation

    Discrepancies between physician notes and lab results regarding albumin levels can cause coding errors and compliance issues.

  • Missing Severity Specificity

    Failing to document the severity of hypoalbuminemia (mild, moderate, severe) impacts accurate coding and quality reporting.

Mitigation Tips

Best Practices
  • Document underlying cause (ICD-10-CM R70.1) for improved CDI.
  • Address malnutrition with high-protein diet, monitor albumin levels.
  • Review medications, consider drug-induced hypoalbuminemia (L65.80).
  • Assess liver function (ICD-10-CM K76.8) for accurate coding.
  • Optimize fluid balance, address edema for compliant care.

Clinical Decision Support

Checklist
  • Verify serum albumin <3.5 g/dL (ICD-10 R76.0, SNOMED CT 119264006)
  • Review medications: nephrotoxic drugs, corticosteroids (patient safety)
  • Assess for edema, ascites: document location and severity (clinical documentation)
  • Check liver function tests, urinalysis for proteinuria (differential diagnosis)
  • Consider nutritional status: dietary intake, malabsorption (SNOMED CT 238347007)

Reimbursement and Quality Metrics

Impact Summary
  • Hypoalbuminemia reimbursement impacted by coding accuracy (ICD-10-CM E88.8, R70.0) and medical necessity documentation.
  • Quality metrics: malnutrition screening, pressure injury, 30-day readmission rates affected by hypoalbuminemia management.
  • Hospital reporting: Case Mix Index (CMI) and Severity of Illness (SOI) may increase with accurate hypoalbuminemia diagnosis coding.
  • Denial management crucial for optimal hypoalbuminemia reimbursement. Focus on clinical validation and coding compliance.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code primary cause of hypoalbuminemia
  • Document serum albumin level
  • Query physician if cause unclear
  • Consider malnutrition, liver disease
  • Check for nephrotic syndrome codes

Documentation Templates

Patient presents with signs and symptoms suggestive of hypoalbuminemia, including edema, fatigue, and ascites.  Relevant medical history includes [insert relevant medical history, e.g., liver cirrhosis, nephrotic syndrome, malnutrition, protein-losing enteropathy].  Physical examination revealed [insert specific physical findings, e.g., pitting edema in bilateral lower extremities, abdominal distension].  Laboratory results confirm hypoalbuminemia with a serum albumin level of [insert value] gdL, which is below the normal range.  Differential diagnosis includes decreased albumin production, increased albumin loss, and hemodilution.  Based on the patient's presentation and laboratory findings, the diagnosis of hypoalbuminemia is established.  Treatment plan includes addressing the underlying cause of the low albumin, such as optimizing management of liver disease, kidney disease, or malnutrition.  Nutritional support with increased protein intake will be initiated.  Patient education regarding dietary modifications and medication adherence was provided.  Follow-up appointment scheduled in [timeframe] to monitor albumin levels and assess treatment response.  ICD-10 code E88.0 for hypoalbuminemia is documented.  Medical coding for albumin level testing and subsequent interventions will be completed per established guidelines. This documentation supports medical necessity for continued treatment and monitoring of the patient's hypoalbuminemia.