ICD-10 Coding for Gluten Allergy(K90.0, K90.41, Z91.038)
Complete ICD-10-CM coding and documentation guide for Gluten Allergy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gluten Allergy
K90.0-K90.49Primary Range
Malabsorption due to intolerance, including celiac disease and non-celiac gluten sensitivity
This range includes codes for celiac disease and non-celiac gluten sensitivity, which are primary conditions related to gluten intolerance.
Personal history of allergy to other foods
This range includes codes for allergies to specific foods, which may be used if gluten allergy is confirmed as IgE-mediated.
Dermatitis herpetiformis
This code is used for dermatitis herpetiformis, a skin condition often associated with celiac disease.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K90.0 | Celiac disease | Use when celiac disease is confirmed by serology and biopsy. |
|
| K90.41 | Non-celiac gluten sensitivity | Use when celiac disease is excluded and symptoms improve on a gluten-free diet. |
|
| Z91.038 | Allergy to other foods | Use when an IgE-mediated allergy to gluten is confirmed. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for gluten allergy
Essential facts and insights about Gluten Allergy
Primary ICD-10-CM Codes for gluten allergy
Decision Criteria
clinical Criteria
- Positive IgA anti-tTG and biopsy confirmation.
Applicable To
- Gluten-sensitive enteropathy
Excludes
- Non-celiac gluten sensitivity (K90.41)
Clinical Validation Requirements
- Positive IgA anti-tTG (≥10 U/mL)
- Marsh Type 3 villous atrophy on duodenal biopsy
Code-Specific Risks
- Misdiagnosis if serology and biopsy are not properly documented.
Coding Notes
- Ensure documentation includes serology and biopsy results.
K90.41 - Non-celiac gluten sensitivity
Use when celiac disease is excluded and symptoms improve on a gluten-free diet.
Applicable To
- Gluten intolerance without celiac disease
Excludes
- Celiac disease (K90.0)
Clinical Validation Requirements
- Negative celiac serology (IgA anti-tTG <4 U/mL)
- Symptom improvement on gluten-free diet
Coding Notes
Document negative serology and symptom resolution.
Z91.038 - Allergy to other foods
Use when an IgE-mediated allergy to gluten is confirmed.
Applicable To
- IgE-mediated gluten allergy
Excludes
- Non-IgE-mediated gluten sensitivity (K90.41)
Clinical Validation Requirements
- IgE-positive wheat/gluten allergy via skin prick test or serum IgE
Coding Notes
Ensure IgE test results are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dermatitis herpetiformis
L13.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gluten Allergy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K90.0.
Impact
Clinical: Inaccurate allergy records affecting patient management., Regulatory: Non-compliance with allergy documentation standards., Financial: Potential claim denials due to lack of evidence.
Mitigation Strategy
Verify IgE test results before documenting allergy., Educate providers on the difference between allergy and sensitivity.
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient care.
Mitigation Strategy
Confirm negative serology and biopsy before assigning K90.41.
Impact
Reimbursement: Potential claim denial due to lack of evidence., Compliance: Violation of coding standards., Data Quality: Misleading allergy records.
Mitigation Strategy
Query provider for IgE test results before coding.
Impact
Misclassification of gluten sensitivity as celiac disease or allergy.
Mitigation Strategy
Regular training on gluten-related disorder coding and documentation.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Gluten Allergy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gluten Allergy
Use these documentation templates to ensure complete and accurate documentation for Gluten Allergy. These templates include all required elements for proper coding and billing.
Gastroenterology Progress Note
Specialty: GastroenterologyRequired Elements
- Chief Complaint
- Assessment
- Diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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