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ICD-10 Guide
ICD-10 CodesR94.4

R94.4

Abnormal results of kidney function studies

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R94.4 is a billable code used to indicate a diagnosis of abnormal results of kidney function studies.

Key Diagnostic Point:

Abnormal results of kidney function studies refer to findings that deviate from the normal range in tests assessing renal function, such as serum creatinine, blood urea nitrogen (BUN), and glomerular filtration rate (GFR). These abnormalities can indicate various underlying conditions, including acute kidney injury, chronic kidney disease, or electrolyte imbalances. Symptoms may include fatigue, swelling, changes in urination patterns, and hypertension. The clinical context is crucial, as these results may arise from dehydration, diabetes, hypertension, or nephrotoxic medications. A comprehensive evaluation often includes a detailed patient history, physical examination, and additional laboratory tests to determine the cause of the abnormal results. The interpretation of these findings requires an understanding of the patient's overall health, comorbidities, and any medications that may affect kidney function.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in normal ranges for kidney function tests based on age, sex, and ethnicity.
  • Need for correlation with clinical symptoms and other diagnostic findings.
  • Potential overlap with other renal-related codes.
  • Documentation requirements for underlying conditions affecting kidney function.

Audit Risk Factors

  • Inadequate documentation of the clinical rationale for testing.
  • Failure to link abnormal results to specific symptoms or diagnoses.
  • Misinterpretation of lab results without considering patient history.
  • Coding without confirming the type of kidney dysfunction (acute vs. chronic).

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including comorbidities and medications, along with lab results.

Common Clinical Scenarios

Patients presenting with fatigue, edema, or hypertension requiring kidney function assessment.

Billing Considerations

Consideration of chronic conditions like diabetes and hypertension that may affect kidney function.

Emergency Medicine

Documentation Requirements

Acute care documentation including vital signs, lab results, and immediate interventions.

Common Clinical Scenarios

Patients with acute renal failure or dehydration presenting with abnormal kidney function tests.

Billing Considerations

Rapid assessment and documentation of acute changes in kidney function.

Coding Guidelines

Inclusion Criteria

Use R94.4 When
  • Follow official ICD
  • CM guidelines for coding symptoms and abnormal findings
  • Ensure that the abnormal results are documented and linked to the patient's clinical presentation

Exclusion Criteria

Do NOT use R94.4 When
No specific exclusions found.

Related CPT Codes

80048CPT Code

Basic metabolic panel

Clinical Scenario

Used to assess kidney function as part of routine lab work.

Documentation Requirements

Document the reason for the metabolic panel and any abnormal findings.

Specialty Considerations

Internal medicine and nephrology may require more detailed documentation.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of kidney function abnormalities, improving the granularity of data for clinical and billing purposes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of kidney function abnormalities, improving the granularity of data for clinical and billing purposes.

Reimbursement & Billing Impact

billing purposes.

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

What should be documented to support the use of R94.4?

Documentation should include the specific abnormal lab results, the clinical context, any symptoms the patient is experiencing, and any relevant medical history that may affect kidney function.