AHA Coding Clinic® for ICD-9 - 1988 Fourth Quarter
Azotemia
Azotemia refers to an alteration in urinary function. It involves an elevated serum concentration of nonprotein nitrogenous compounds, primarily urea nitrogen, but also creatinine, amino acids, uric acids, creatine, and ammonia. Azotemia is produced by diminished glomerular filtration of these compounds by the kidney. Azotemia may be further described as prerenal, postrenal, or renal azotemia states. Prerenal azotemia, 788.9, postrenal azotemia, 788.9, and azotemia (renal), 790.6, refer to marked elevation of urea nitrogen (and creatine). However, the term azotemia may be used in reference to the presence of acute renal failure, 584.9, or chronic renal...
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Article Overview
This article reviews azotemia as a kidney-related finding and discusses how it is described in relation to prerenal, postrenal, and renal states. It is aimed at medical coders and coding staff who need to understand the documentation context, related renal terminology, and the general coding categories referenced in the discussion. The article also notes a kidney disease title change effective in 2005 and includes brief examples of related diagnostic pairings.
Why This Topic Matters
Clarifying what a provider means by azotemia can affect whether the record is captured as a symptom/sign finding or as part of a broader renal diagnosis. The article highlights why documentation specificity matters when renal failure or chronic kidney disease is involved.
Article Sections
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Overview of azotemia
Introduces azotemia as a kidney-related laboratory and urinary function finding. It outlines the broad clinical categories used to describe the condition.
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Prerenal, postrenal, and renal azotemia
Summarizes the major physiologic groupings discussed in the article. This section addresses the general context for documentation and coding of each category.
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Coding considerations and documentation clarification
Explains how azotemia may be referenced in records alongside other renal diagnoses and why additional physician clarification may be needed. It also discusses the general relationship between azotemia and symptom/sign coding.
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Note on chronic kidney disease terminology
Describes the reported title change for a chronic renal condition and the effective date mentioned in the article. It provides background on the evolution of the referenced diagnosis category.
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Examples of related diagnostic pairings
Presents short example pairings showing azotemia in the context of other diagnoses. These examples are included to illustrate the kinds of record combinations discussed in the article.
What You Will Learn
- How azotemia is discussed as a clinical finding in relation to kidney function
- The general distinctions among prerenal, postrenal, and renal azotemia
- Why documentation specificity can matter when azotemia appears in a record
- How the article relates azotemia to broader renal failure and chronic kidney disease terminology
- The types of example diagnostic pairings mentioned in the discussion
Who Should Read This
- Medical coders
- Coding managers
- Clinical documentation staff
- Revenue cycle professionals
- Health information management staff
Codes Discussed
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