Kidney Stones: Diagnosis, ICD-10 Coding, and Streamlined Documentation

Updated on: July 30, 2025

Kidney stones, or renal calculi, are one of the most common and painful urologic conditions seen in clinical practice. With prevalence on the rise due to diet, dehydration, and metabolic factors, clinicians are increasingly tasked with managing both acute stone episodes and long-term stone prevention.

But beyond clinical care, accurately documenting and coding kidney stones is vital for proper diagnosis tracking, treatment planning, and reimbursement. In this guide, we’ll cover:

• What causes kidney stones and how they present

• Diagnostic approaches and treatment strategies

• ICD-10 coding for various stone locations

• Documentation best practices

• How DocScrib helps streamline urology and nephrology workflows

What Are Kidney Stones?

Kidney stones are crystal aggregations formed from minerals in the urine—most commonly calcium oxalate or calcium phosphate. They can form anywhere along the urinary tract, including:

• Kidneys (nephrolithiasis)

• Ureters (ureterolithiasis)

• Bladder (cystolithiasis)

While some stones are passed spontaneously, others may cause obstruction, pain, hematuria, or infection, requiring intervention.

Common Symptoms of Kidney Stones

Kidney stones often present with sudden, severe flank pain, sometimes radiating to the groin. Additional symptoms include:

• Hematuria (gross or microscopic)

• Nausea and vomiting

• Dysuria or urinary urgency

• Fever and chills (suggesting infection)

• Restlessness or inability to find a comfortable position

Risk Factors

• Low fluid intake

• High sodium or animal protein diet

• Hyperparathyroidism

• Family history of stones

• Obesity

• Certain medications (e.g., topiramate, loop diuretics)

Diagnostic Evaluation

Initial workup includes:

• Non-contrast CT scan (gold standard)

• Renal ultrasound (especially in pregnancy)

• Urinalysis (for hematuria, crystals, pH)

• Serum creatinine and BUN

• Stone analysis (if passed or removed)

ICD-10 Coding for Kidney Stones

Accurate ICD-10 coding helps reflect the location, laterality, and complication status of the stone.

Common ICD-10 Codes for Kidney Stones

✅ Use N20.2 when both renal and ureteral stones are present, as seen on imaging or during treatment.

Sample Clinical Documentation: SOAP Note

Subjective:
“Patient presents with severe right flank pain radiating to the groin for the past 4 hours. Associated with nausea and one episode of vomiting. No fever.”

Objective:
T: 98.6°F, HR: 98, BP: 140/90. CVAT positive on right. Urinalysis shows +3 blood, no nitrates or leukocytes. Non-contrast CT reveals a 6mm obstructing stone in the right distal ureter.

Assessment:
Acute right-sided ureterolithiasis with hematuria.
ICD-10: N20.1, R31.9

Plan:

• Initiate IV fluids and ketorolac

• Alpha-blocker (tamsulosin) 0.4 mg daily for 10 days

• Strain urine; follow up in 7 days or if symptoms worsen

• Consider urology referral if stone not passed

Treatment Options for Kidney Stones

⚠️ Urgent intervention is needed in patients with infection, sepsis, or obstruction.

Chronic Kidney Stone Management

Patients with recurrent stones require metabolic evaluation, including:

• 24-hour urine collection

• Serum calcium, uric acid, phosphate, citrate

• Dietary counseling

• Thiazide diuretics or citrate supplementation

• Periodic imaging

Documenting “history of kidney stones” (Z87.440) in these cases is essential for tracking and reimbursement.

Common Documentation Pitfalls

🚫 Coding only “pain” without identifying the underlying cause (e.g., N20.1)
🚫 Using N20.9 when more specific location is known
🚫 Failing to update the problem list with history of stones (Z87.440)
🚫 Not documenting imaging results or follow-up plan

How DocScrib Simplifies Urology and Renal Documentation

Charting for urology and nephrology patients—especially those with acute or chronic kidney stones—can be time-consuming. That’s where DocScrib makes a difference.

With DocScrib, You Can:

✅ Autogenerate clinical notes based on patient-provider conversations
✅ Auto-suggest relevant ICD-10 codes like N20.0, N20.1, or Z87.440
✅ Document imaging findings and track stone location with anatomical specificity
✅ Reduce documentation time by 70%
✅ Maintain complete, compliant records—ideal for billing and continuity of care

Start automating your urology documentation today.
👉 Book your free demo now

Quick Reference: Kidney Stone ICD-10 Code Summary

FAQs

Q1: Can I code both N20.1 and N20.0 if stones are found in both locations?
Yes, but using N20.2 is more specific and often preferred when both renal and ureteral stones are present simultaneously.

Q2: Should I always include Z87.440 for patients with past stones?
Yes—especially if they are under surveillance or at high risk for recurrence.

Q3: Does DocScrib recognize imaging findings like “distal ureteral stone”?
Absolutely. DocScrib can convert dictated or written impressions into structured notes and coded diagnoses like N20.1.

Q4: How often should metabolic workup be documented in chronic stone formers?
At least annually or with recurrence. Use Z87.440 along with any active findings to justify labs or imaging.

Final Thoughts

Kidney stones remain one of the most painful yet manageable urologic conditions. Whether it’s acute flank pain, obstructive uropathy, or chronic stone prevention, effective care starts with accurate diagnosis, clear documentation, and correct ICD-10 coding.

With DocScrib, clinicians can streamline this entire process—from symptom capture and imaging interpretation to automated coding and note generation.

👉 Book your free demo of DocScrib now and optimize your kidney stone documentation workflow.