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ICD-10 Guide
ICD-10 CodesN28.9

N28.9

Billable

Disorder of kidney and ureter, unspecified

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N28.9 is a billable code used to indicate a diagnosis of disorder of kidney and ureter, unspecified.

Key Diagnostic Point:

N28.9 is used to classify disorders of the kidney and ureter that are not specified elsewhere in the ICD-10 coding system. This code encompasses a variety of conditions that may affect the kidneys and ureters, including but not limited to ischemic nephropathy, small kidney (hypoplasia), and other unspecified kidney disorders. Ischemic nephropathy refers to kidney damage due to reduced blood flow, often resulting from vascular diseases. Small kidney disorders may arise from congenital conditions or chronic diseases leading to renal atrophy. The unspecified nature of this code indicates that the clinician has not provided a more specific diagnosis, which can complicate treatment and management. Accurate coding is essential for proper reimbursement and to ensure that patients receive appropriate care based on their underlying conditions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Lack of specificity in the diagnosis
  • Variability in clinical presentation
  • Potential overlap with other kidney disorders
  • Need for comprehensive documentation to support the diagnosis

Audit Risk Factors

  • Insufficient documentation to support the unspecified diagnosis
  • Inconsistent use of the code across different encounters
  • Failure to link the diagnosis to the treatment provided
  • Use of the code when a more specific diagnosis is available

Specialty Focus

Medical Specialties

Nephrology

Documentation Requirements

Detailed clinical notes including patient history, physical examination findings, and diagnostic test results.

Common Clinical Scenarios

Patients presenting with renal insufficiency, unexplained renal symptoms, or incidental findings on imaging.

Billing Considerations

Ensure that all relevant tests and evaluations are documented to justify the use of N28.9.

Urology

Documentation Requirements

Comprehensive documentation of urinary symptoms, imaging studies, and any surgical interventions.

Common Clinical Scenarios

Patients with urinary obstruction, renal stones, or unexplained hematuria.

Billing Considerations

Linking the diagnosis to specific urological procedures performed.

Coding Guidelines

Inclusion Criteria

Use N28.9 When
  • According to ICD
  • 10 coding guidelines, N28
  • 9 should be used when no other specific code applies
  • Coders should ensure that the documentation supports the use of this code and that it is not used when a more specific diagnosis is available

Exclusion Criteria

Do NOT use N28.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

76770CPT Code

Ultrasound, abdomen, complete

Clinical Scenario

Used to evaluate kidney size and structure when N28.9 is diagnosed.

Documentation Requirements

Document the reason for the ultrasound and findings related to kidney disorders.

Specialty Considerations

Nephrologists and urologists should ensure that the ultrasound findings correlate with the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more detailed coding of kidney disorders, but the use of unspecified codes like N28.9 can lead to challenges in reimbursement and care management. Coders must ensure that they are using the most specific codes available to reflect the patient's condition accurately.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more detailed coding of kidney disorders, but the use of unspecified codes like N28.9 can lead to challenges in reimbursement and care management. Coders must ensure that they are using the most specific codes available to reflect the patient's condition accurately.

Reimbursement & Billing Impact

reimbursement and care management. Coders must ensure that they are using the most specific codes available to reflect the patient's condition accurately.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use N28.9?

N28.9 should be used when there is a disorder of the kidney or ureter that does not have a more specific diagnosis available. Ensure that the documentation supports the use of this code.