Find information on documenting and coding a personal history of kidney stones. This guide covers clinical documentation requirements, ICD-10 codes (Z87.5), medical coding guidelines, and best practices for healthcare professionals dealing with patients with a past history of nephrolithiasis or renal calculi. Learn about relevant medical history, diagnosis codes, and proper terminology for accurate and efficient healthcare record keeping related to a history of kidney stones.
Also known as
Personal history of urinary stones
Past kidney stones, now resolved or inactive.
Calculus of kidney and ureter
Although active stones, may be relevant to history.
Family history of urinary stones
While family history, can inform risk and personal history context.
Follow this step-by-step guide to choose the correct ICD-10 code.
History of kidney stones?
Yes
Stones currently present?
No
DO NOT code Z85.0. Evaluate for other diagnoses.
When to use each related code
| Description |
|---|
| Kidney stone history |
| Nephrolithiasis |
| Renal colic |
Coding lacks specificity (e.g., calcium, struvite) impacting data accuracy and reimbursement. CDI can clarify.
Incorrectly coding active kidney stones as history can lead to overcoding and compliance issues. Review documentation.
Missing laterality (left, right, bilateral) can affect statistical reporting and future treatment plans. Query physician.
Q: How can I differentiate between a patient presenting with renal colic from a kidney stone versus other acute abdominal pain etiologies in the emergency department?
A: Differentiating renal colic from kidney stones versus other acute abdominal pain etiologies requires a thorough clinical approach. Consider the classic presentation of sudden, severe, colicky flank pain radiating to the groin, often accompanied by nausea and vomiting. Hematuria may be present but is not always a reliable indicator. A detailed patient history focusing on risk factors such as family history, dietary habits (high oxalate or sodium intake), and prior stone episodes is crucial. Physical examination including costovertebral angle tenderness can further guide your suspicion. However, imaging studies such as a non-contrast CT scan of the abdomen and pelvis are typically the gold standard for definitive diagnosis, allowing for visualization of the stone and assessment of its size and location. Explore how point-of-care ultrasound can be used as a quick and non-invasive initial assessment tool to identify hydronephrosis, particularly in resource-limited settings or to avoid unnecessary radiation exposure in select patients. Always consider other differential diagnoses like appendicitis, pyelonephritis, or ovarian torsion, particularly in women, and tailor your diagnostic workup accordingly. Consider implementing a standardized diagnostic pathway for suspected kidney stones in your emergency department to streamline care and ensure timely diagnosis.
Q: What are the best evidence-based strategies for preventing recurrent kidney stones in patients with a personal history of calcium oxalate stones?
A: Preventing recurrent calcium oxalate kidney stones requires a multi-pronged approach targeting modifiable risk factors. Increased fluid intake to achieve a urine output of at least 2-2.5 liters per day is paramount. Dietary modifications play a significant role, including reducing sodium intake, limiting animal protein, and moderating oxalate-rich foods like spinach, nuts, and chocolate. Consider implementing a 24-hour urine collection to identify specific metabolic abnormalities like hypercalciuria, hyperoxaluria, or hypocitraturia, which can inform targeted medical management. Thiazide diuretics can reduce calcium excretion, while potassium citrate can increase urine citrate levels, inhibiting stone formation. For patients with persistently elevated urine oxalate levels despite dietary changes, oxalate-degrading gut bacteria therapies may be beneficial. Learn more about the role of genetic testing in identifying patients at higher risk of recurrence and tailoring individualized prevention strategies. Regular follow-up and patient education are crucial for long-term success in preventing future stone episodes.
The patient presents with a personal history of kidney stones (nephrolithiasis), confirmed by previous imaging and laboratory studies. The patient reports a history of renal colic, flank pain, hematuria, and urinary urgency. The specific type of kidney stone composition (calcium oxalate, uric acid, struvite, cystine) has been documented as [insert stone type if known, otherwise state "unknown"]. Frequency of prior stone events is noted as [insert frequency, e.g., "single episode," "recurrent," "chronic"]. Date of last stone event is documented as [insert date or "unknown"]. Associated symptoms during previous stone events included [list symptoms, e.g., nausea, vomiting, dysuria]. Prior treatments for nephrolithiasis have included [list treatments, e.g., medical expulsive therapy, lithotripsy, ureteroscopy]. Current management focuses on preventive measures, including [list current preventive measures, e.g., increased fluid intake, dietary modifications, medications]. Patient education provided regarding kidney stone prevention, dietary recommendations, and recognizing symptoms of recurrence. Patient understands the importance of follow-up care and monitoring for future stone events. Assessment for risk factors such as family history of kidney stones, dehydration, dietary habits, and metabolic conditions has been conducted. Plan includes ongoing monitoring of renal function and continued patient education regarding lifestyle modifications to minimize risk of recurrence. Diagnosis codes for this encounter include [insert relevant ICD-10 codes, e.g., N71.8, N71.0, N71.9].