ICD-10 Coding for Gluten Sensitivity(K90.41, K90.0)
Complete ICD-10-CM coding and documentation guide for Gluten Sensitivity. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gluten Sensitivity
K90.4-K90.49Primary Range
Malabsorption due to intolerance, including gluten sensitivity
This range includes codes for malabsorption syndromes related to gluten sensitivity, specifically non-celiac gluten sensitivity.
Celiac disease
This code is used for celiac disease, which must be differentiated from non-celiac gluten sensitivity.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K90.41 | Non-celiac gluten sensitivity | Use when non-celiac gluten sensitivity is confirmed and celiac disease is excluded. |
|
| K90.0 | Celiac disease | Use when celiac disease is confirmed by serology and biopsy. |
|
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 sensitivity
Essential facts and insights about Gluten Sensitivity
Primary ICD-10-CM Codes for gluten sensitivity
Decision Criteria
clinical Criteria
- Negative celiac serology and symptom improvement on gluten-free diet
documentation Criteria
- Explicit mention of non-celiac gluten sensitivity
Applicable To
- Gluten intolerance without celiac disease
Clinical Validation Requirements
- Negative tTG IgA and DGP IgG
- Normal duodenal biopsy
- Symptom resolution on gluten-free diet
Code-Specific Risks
- Confusion with celiac disease or wheat allergy
Coding Notes
- Ensure documentation specifies non-celiac gluten sensitivity and excludes celiac disease.
K90.0 - Celiac disease
Use when celiac disease is confirmed by serology and biopsy.
Applicable To
- Celiac disease with steatorrhea
Excludes
- Non-celiac gluten sensitivity (K90.41)
Clinical Validation Requirements
- Positive tTG IgA/EMA
- Villous atrophy on biopsy
- HLA-DQ2/DQ8 positivity
Coding Notes
Ensure documentation includes serology and biopsy results confirming celiac disease.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gluten Sensitivity to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K90.41.
Impact
Clinical: Misrepresents patient's condition, Regulatory: Non-compliance with coding standards, Financial: Potential reimbursement issues
Mitigation Strategy
Verify serology and biopsy results, Use correct code based on documentation
Impact
Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: May result in audit issues if documentation does not support the code used., Data Quality: Affects accuracy of patient records and data reporting.
Mitigation Strategy
Ensure serology and biopsy results are documented to differentiate between conditions.
Impact
Risk of using incorrect codes for gluten-related disorders
Mitigation Strategy
Ensure thorough documentation and review of serology and biopsy results.
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 Sensitivity, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gluten Sensitivity
Use these documentation templates to ensure complete and accurate documentation for Gluten Sensitivity. These templates include all required elements for proper coding and billing.
Gastroenterology Progress Note for NCGS
Specialty: GastroenterologyRequired Elements
- Symptom assessment
- Serology results
- Biopsy results
- Dietary response
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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