Facebook tracking pixel
N28.89
ICD-10-CM
Perinephric Hematoma

Find information on perinephric hematoma diagnosis, including clinical documentation, ICD-10 codes (N28.89, S37.0), medical coding guidelines, and treatment options. Learn about symptoms, causes, radiological findings (CT scan, ultrasound), and best practices for healthcare professionals managing perirenal hematoma and renal hemorrhage. Explore resources for accurate and efficient medical record keeping related to kidney injuries and bleeding.

Also known as

Perirenal Hematoma
Subcapsular Renal Hematoma

Diagnosis Snapshot

Key Facts
  • Definition : Blood collection around the kidney, usually due to trauma.
  • Clinical Signs : Flank pain, bruising, tenderness, and possible signs of shock.
  • Common Settings : Trauma centers, emergency rooms, and operating rooms.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC N28.89 Coding
S37.0

Injury of kidney

This code specifies injuries to the kidney, including perinephric hematoma.

S30-S39

Injuries to the abdomen, lower back

This range encompasses various injuries to the abdomen and lower back, sometimes resulting in perinephric hematoma.

T86.1

Hemorrhage and hematoma complicating a procedure

This code can be used if the hematoma is a complication of a medical procedure.

Code-Specific Guidance

Decision Tree for

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

Is the perinephric hematoma traumatic?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Blood collection around kidney
Kidney bleed within capsule
Kidney laceration

Documentation Best Practices

Documentation Checklist
  • Document cause of perinephric hematoma (trauma, surgery, etc.)
  • Size and location of hematoma precisely documented using imaging reports
  • Signs/symptoms: flank pain, hematuria, hypotension documented
  • Labs: hemoglobin, hematocrit, coagulation studies results
  • Treatment plan: observation, intervention (if any) specified

Coding and Audit Risks

Common Risks
  • Unspecified Cause

    Coding perinephric hematoma without documenting the cause (traumatic vs. spontaneous) leads to coding errors and claim denials.

  • Laterality Missing

    Failing to document laterality (right, left, bilateral) for perinephric hematoma impacts coding specificity and reimbursement.

  • Iatrogenic vs. Non-iatrogenic

    Distinguishing between iatrogenic (procedure-related) and non-iatrogenic hematomas is crucial for accurate coding and quality reporting.

Mitigation Tips

Best Practices
  • Document trauma mechanism for accurate ICD-10-CM S37.xxx coding.
  • Clearly specify hematoma location (perinephric) in operative reports for CDI.
  • Correlate imaging (CT/MRI) with clinical findings for compliant S37.xxx justification.
  • Query physician for bleed source to ensure complete HCC coding compliance.
  • Monitor renal function, document changes for accurate severity coding (N17.x).

Clinical Decision Support

Checklist
  • Verify history of trauma, anticoagulant use, or bleeding disorder
  • Confirm flank pain, ecchymosis, and hypotension signs
  • Check imaging (CT scan) for perinephric fluid collection
  • Review labs for declining hemoglobin and hematocrit
  • Assess for signs of hemorrhagic shock and renal dysfunction

Reimbursement and Quality Metrics

Impact Summary
  • Perinephric Hematoma: Reimbursement and Quality Metrics Impact Summary
  • Keywords: perinephric hematoma, ICD-10, medical billing, coding, reimbursement, quality metrics, hospital reporting, DRG, APR-DRG, complication, morbidity, mortality
  • Impact 1: Accurate ICD-10 coding (N28.89, S37.8XXA, etc.) impacts DRG assignment and reimbursement.
  • Impact 2: Hematoma as a complication increases APR-DRG severity, affecting hospital quality scores.
  • Impact 3: Delays in diagnosis/treatment can negatively impact patient outcomes and hospital mortality rates.
  • Impact 4: Proper documentation is crucial for accurate coding, justified reimbursement, and quality reporting.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code injury with perinephric hematoma
  • Query physician for cause
  • Document size/location
  • Check laterality (ICD-10-CM)
  • Consider S78.4/S78.5

Documentation Templates

Patient presents with complaints consistent with perinephric hematoma, including flank pain, abdominal pain, and hematuria.  Symptoms onset was [timeframe] and associated with [precipitating event, if any, e.g., trauma, anticoagulant therapy, interventional procedure, spontaneous bleed].  Review of systems reveals [positive findings related to pain, bleeding, urinary symptoms, or systemic effects e.g., dizziness, lightheadedness, nausea, vomiting].  Physical examination reveals [positive and pertinent negative findings e.g., flank tenderness, ecchymosis, palpable mass, stable vital signs].  Differential diagnosis includes renal trauma, renal cell carcinoma, renal infarction, retroperitoneal hemorrhage, and aortic aneurysm.  Imaging studies, including [mention specific imaging like CT scan abdomen and pelvis with IV contrast, ultrasound], were ordered to evaluate for perinephric bleeding and assess the extent of the hematoma.  Laboratory tests, including [mention specific labs like CBC, coagulation panel, urinalysis, BUN, creatinine], were ordered to evaluate for active bleeding, assess renal function, and identify any coagulopathy.  Impression: Perinephric hematoma, likely secondary to [cause, e.g., blunt trauma, anticoagulant therapy].  Management plan includes [specific management plan, e.g., monitoring vital signs, serial imaging, pain management, correction of coagulopathy if present, urology consultation, surgical intervention if indicated].  Patient education provided regarding the diagnosis, treatment plan, and potential complications.  Follow-up scheduled for [timeframe] to re-evaluate and assess response to treatment.  Patient advised to return to the emergency department if symptoms worsen or new symptoms develop.  ICD-10 code S37.01XA (Traumatic subcapsular or perinephric hematoma of right kidney with active bleeding) or S37.02XA (Traumatic subcapsular or perinephric hematoma of left kidney with active bleeding) may be applicable depending on laterality and presence of active bleeding; other codes may be necessary depending on etiology and complications.