“With”
The word “with” or “in” should be interpreted to mean “associated with” or ”due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List.
Is it a definitive diagnosis with the word "likely" due to?Per ICD-10-CM guidelines, Section I., A., 15.,
For N17.0, “Acute kidney failure with tubular necrosis” is thus interpreted as “Acute kidney failure due to tubular necrosis”. This is in agreement with the provider’s diagnosis: “oliguric acute kidney injury likely secondary to multifactorial ATN”.
“Acute kidney injury” and ”acute kidney (renal) failure” are synonymous (Goyal et al., 2023).
Therefore, N17.0 would be the proper code.
Also, whatever the “multifactorial” causes are for the tubular necrosis, you need to code them as underlying conditions, per the instruction under N17 in the ICD-10-CM manual.
References
Goyal, A., Daneshpajouhnejad, P., & Hashmi, M. F. (2023, November 25). Acute kidney injury. In StatPearls. StatPearls Publishing. Retrieved June 16, 2024, from https://www.ncbi.nlm.nih.gov/books/NBK441896/
The original post stated “in a hospital note” from which I inferred the patient was an inpatient. If that indeed is the case, yes, it is a diagnosis one would code.Is it a definitive diagnosis with the word "likely" due to?
H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Hello, Could someone please clarify/confirm if I understood this coding guidance correctly? Coding Guidance- Inpatient setting: Uncertain Diagnosis at the time of Discharge. I am coding for physicians, not for the facility. So this rule I will read as:
1. For inpatient services provided by MD, I canNotuse 'uncertain dx' at the Discharge.
2. For inpatient services by hospital/facility, I Can use 'uncertain dx" at the Discharge.
Thank you very much in advance.