Learn about accurate diagnosis coding and clinical documentation for Vitamin D Deficiency. This resource covers history of Vitamin D Deficiency, including ICD-10 codes, SNOMED CT codes, diagnostic criteria, and medical necessity documentation for optimal reimbursement. Explore best practices for charting past Vitamin D deficiency, including low Vitamin D symptoms, lab results, and treatment history. Improve your healthcare documentation and coding accuracy for Vitamin D Deficiency diagnosis.
Also known as
Vitamin D deficiency
Covers unspecified vitamin D deficiency.
Unspecified nutritional deficiency
May be used if specific vitamin D detail is lacking.
Personal history of vitamin D deficiency
Indicates past vitamin D deficiency, now resolved.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the Vitamin D deficiency currently active?
Yes
Do NOT code history. Code active Vitamin D deficiency (E55.9).
No
Is there any documented residual effect?
When to use each related code
| Description |
|---|
| Vitamin D deficiency |
| Rickets (children) |
| Osteomalacia (adults) |
Coding E55.9 (Vitamin D deficiency, unspecified) without documenting the specific type (e.g., nutritional, after gastrectomy) can lead to denials.
Failing to document the severity or acuity (active vs. history of) can impact reimbursement and quality reporting. CDI should query for clarity.
Discrepancies between physician documentation and lab results regarding vitamin D levels create compliance risks and require physician clarification.
Patient presents with a history of vitamin D deficiency (hypovitaminosis D). Past medical history includes [insert relevant past medical history, e.g., malabsorption syndromes, gastric bypass surgery, limited sun exposure, dietary restrictions, or use of medications interfering with vitamin D absorption]. Patient may report symptoms consistent with vitamin D deficiency such as muscle weakness, bone pain, fatigue, or depression. Previous lab results confirmed low 25-hydroxyvitamin D levels (below 20 ngmL), indicating insufficient vitamin D status. Differential diagnosis considered hypoparathyroidism, osteomalacia, and osteoporosis. Assessment includes review of dietary intake of vitamin D, sun exposure habits, and family history of vitamin D deficiency. Plan includes vitamin D supplementation with [specify dose and frequency, e.g., cholecalciferol 50,000 IU weekly] to address the vitamin D insufficiency. Patient education provided on the importance of vitamin D for bone health, calcium absorption, and overall well-being. Follow-up appointment scheduled to monitor 25-hydroxyvitamin D levels and assess response to treatment. ICD-10 code E55.9 Vitamin D deficiency, unspecified is assigned. Monitoring for improvement in symptoms and achieving optimal vitamin D levels will be essential for long-term health management.