ICD-10 Coding for Gluten Intolerance(K90.41)
Complete ICD-10-CM coding and documentation guide for Gluten Intolerance. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gluten Intolerance
K90.41Primary Range
Non-Celiac Gluten Sensitivity
This code is used for patients diagnosed with gluten sensitivity after excluding celiac disease and wheat allergy.
Key Information: ICD-10 code for gluten intolerance
Essential facts and insights about Gluten Intolerance
Primary ICD-10-CM Code for gluten intolerance
Decision Criteria
clinical Criteria
- Negative celiac serology and symptom improvement on a gluten-free diet.
documentation Criteria
- Document exclusion of celiac disease and wheat allergy.
Applicable To
- Gluten intolerance
- Non-celiac gluten sensitivity
Clinical Validation Requirements
- Negative tTG IgA and normal total IgA
- Negative wheat IgE test
- Symptom improvement on a gluten-free diet
Code-Specific Risks
- Misclassification with celiac disease
- Inadequate documentation of exclusion tests
Coding Notes
- Ensure documentation clearly excludes celiac disease and wheat allergy.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Right upper quadrant pain
R10.11Abnormal weight loss
R63.4Functional diarrhea
K59.1Dietary counseling and surveillance
Z71.3Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gluten Intolerance to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K90.41.
Impact
Clinical: Leads to misdiagnosis and inappropriate treatment., Regulatory: May result in audit findings., Financial: Can cause claim denials.
Mitigation Strategy
Use specific terms like 'non-celiac gluten sensitivity'., Document test results and dietary response.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Misclassification can trigger audits., Data Quality: Affects accuracy of patient records.
Mitigation Strategy
Ensure negative serology and biopsy results are documented.
Impact
Incorrectly coding gluten sensitivity as celiac disease.
Mitigation Strategy
Ensure thorough documentation of exclusion tests.
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 Intolerance, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gluten Intolerance
Use these documentation templates to ensure complete and accurate documentation for Gluten Intolerance. These templates include all required elements for proper coding and billing.
Diagnosis of NCGS in a gastroenterology clinic
Specialty: GastroenterologyRequired Elements
- Patient symptoms
- Negative celiac serology
- Negative wheat allergy test
- Symptom improvement on gluten-free diet
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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