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
Disorders of plasma protein metabolism
Includes hypoalbuminemia not due to dietary deficiency.
Malnutrition
May include hypoalbuminemia due to severe protein deficiency.
Cachexia
Often associated with hypoalbuminemia due to underlying illness.
Diseases of liver
Liver disease can cause hypoalbuminemia due to reduced synthesis.
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?
When to use each related code
Description |
---|
Low blood albumin levels. |
Malnutrition, protein deficiency. |
Liver cirrhosis, impaired synthesis. |
Coding hypoalbuminemia without documenting the underlying cause leads to inaccurate coding and potential DRG misassignment.
Discrepancies between physician notes and lab results regarding albumin levels can cause coding errors and compliance issues.
Failing to document the severity of hypoalbuminemia (mild, moderate, severe) impacts accurate coding and quality reporting.
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.