Find information on low sodium (hyponatremia) diagnosis, including causes, symptoms, treatment, and management. Learn about relevant clinical documentation tips for accurate medical coding and billing, covering ICD-10 codes for hyponatremia, serum sodium levels, electrolyte imbalance, and fluid balance. This resource provides guidance for healthcare professionals on documenting hyponatremia in patient charts and ensuring proper reimbursement. Explore the latest guidelines for diagnosing and managing low sodium levels in patients.
Also known as
Hyponatremia
Low sodium levels in the blood.
Volume depletion
Conditions related to fluid loss, which can cause hyponatremia.
Hyposmolality and hyponatremia
Low concentration of solutes and sodium in the blood.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is hyponatremia due to a drug?
Yes
Specify drug if known
No
Is it due to excessive water intake?
When to use each related code
Description |
---|
Low sodium levels in blood. |
Syndrome of inappropriate ADH |
Fluid overload (hypervolemia) |
Coding hyponatremia without specifying acute/chronic or cause (e.g., dilutional) leads to inaccurate severity and reimbursement.
Failing to capture underlying causes of low sodium (e.g., CHF, SIADH) impacts risk adjustment and quality metrics.
Insufficient documentation of serum sodium levels or lab test timing hinders accurate coding and clinical validation.
Patient presents with hyponatremia, low sodium levels, demonstrating symptoms consistent with a sodium deficiency. Onset of symptoms, including [insert specific symptoms e.g., nausea, vomiting, headache, confusion, lethargy, muscle weakness, cramps, seizures], began [ timeframe e.g., two days ago, gradually over the past week]. Patient reports [mention contributing factors e.g., excessive fluid intake, diuretic use, recent illness, dietary changes]. Serum sodium concentration measured [numeric value] mEqL, confirming hyponatremia diagnosis. Differential diagnosis includes SIADH (syndrome of inappropriate antidiuretic hormone secretion), CHF (congestive heart failure), cirrhosis, renal failure, and hypothyroidism. Assessment reveals [list objective clinical findings e.g., decreased skin turgor, orthostatic hypotension, altered mental status]. Treatment plan includes [specify interventions e.g., fluid restriction, sodium replacement therapy with oral sodium chloride tablets or intravenous normal saline, address underlying cause]. Patient education provided on hyponatremia management, dietary sodium guidelines, and importance of follow-up care. ICD-10 code E87.1, Hyponatremia, assigned. Monitoring of serum sodium levels and clinical response to treatment will continue. Further investigations to determine the etiology of hyponatremia are warranted, including [list planned tests e.g., urine sodium, serum osmolality, thyroid function tests, renal panel]. Prognosis depends on the underlying cause and response to therapy.