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E87.1
ICD-10-CM
Low Sodium

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 Serum Sodium

Diagnosis Snapshot

Key Facts
  • Definition : Low blood sodium (hyponatremia) occurs when sodium levels are below 135 mEq/L.
  • Clinical Signs : Nausea, headache, confusion, fatigue, muscle weakness, seizures, or coma.
  • Common Settings : Hospital, clinic, nursing home, or home care setting.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC E87.1 Coding
E87.1

Hyponatremia

Low sodium levels in the blood.

E86.0-E86.9

Volume depletion

Conditions related to fluid loss, which can cause hyponatremia.

R78.0

Hyposmolality and hyponatremia

Low concentration of solutes and sodium in the blood.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Low sodium levels in blood.
Syndrome of inappropriate ADH
Fluid overload (hypervolemia)

Documentation Best Practices

Documentation Checklist
  • Hyponatremia diagnosis specifics
  • Serum sodium level <135 mEq/L
  • Document symptoms (e.g., nausea, headache)
  • Underlying cause if known (e.g., diuretics)
  • Treatment plan details (fluid restriction, etc.)

Coding and Audit Risks

Common Risks
  • Unspecified Hyponatremia

    Coding hyponatremia without specifying acute/chronic or cause (e.g., dilutional) leads to inaccurate severity and reimbursement.

  • Missed Secondary Diagnoses

    Failing to capture underlying causes of low sodium (e.g., CHF, SIADH) impacts risk adjustment and quality metrics.

  • Inaccurate Sodium Level Documentation

    Insufficient documentation of serum sodium levels or lab test timing hinders accurate coding and clinical validation.

Mitigation Tips

Best Practices
  • Document cause of hyponatremia: ICD-10-CM E87.1, CDI query
  • Fluid restriction, monitor I/O, daily weights: accurate clinical documentation
  • Loop diuretic use review, evaluate other meds: medication reconciliation, compliance
  • Treat underlying condition, slow sodium correction: patient safety, quality of care
  • Monitor sodium levels, assess neuro status: avoid rapid changes, risk management

Clinical Decision Support

Checklist
  • Verify serum sodium <135 mEq/L documented
  • Assess fluid status (hypovolemia, hypervolemia)
  • Review medications impacting sodium levels
  • Check urine sodium/osmolality for SIADH diagnosis

Reimbursement and Quality Metrics

Impact Summary
  • Low Sodium (Hyponatremia) Reimbursement: Diagnosis coding (ICD-10-CM E87.1) accuracy impacts MS-DRG assignment and case-mix index, affecting hospital reimbursement.
  • Quality Metrics Impact: Hyponatremia management affects quality reporting metrics related to electrolyte imbalances, patient safety, and readmission rates.
  • Coding Accuracy Impact: Correctly specifying acute, chronic, or other related conditions (e.g., SIADH) impacts severity level and reimbursement.
  • Hospital Reporting Impact: Accurate hyponatremia documentation and coding are crucial for internal quality improvement initiatives and public health reporting.

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 hyponatremia specifics
  • Document sodium levels, cause
  • Check for fluid status, meds
  • Query physician if unclear
  • Consider central pontine coding

Documentation Templates

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.