Learn about Vitamin D Deficiency diagnosis including ICD-10 code E55.9, clinical documentation requirements, differential diagnosis, lab tests (25-hydroxyvitamin D), symptoms, treatment, and prevention. Find information for healthcare professionals, medical coders, and patients regarding Vitamin D Deficiency screening, risk factors, and best practices for accurate medical record keeping. Explore resources related to hypovitaminosis D and its impact on bone health, calcium absorption, and overall wellness.
Also known as
Vitamin D deficiency
Unspecified vitamin D deficiency.
Rickets, active
Active rickets due to vitamin D deficiency.
Osteomalacia, NOS
Softening of the bones in adults, often due to vitamin D deficiency.
Other nutritional deficiencies
May include secondary deficiencies related to vitamin D malabsorption.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the Vitamin D deficiency drug induced?
Yes
Which drug caused it?
No
Is there rickets?
When to use each related code
| Description |
|---|
| Vitamin D deficiency |
| Osteomalacia |
| Rickets |
Using unspecified Vitamin D deficiency codes (E55.9) when a more specific code (e.g., E55.0) is documented, impacting reimbursement and data accuracy.
Insufficient documentation of Vitamin D levels or symptoms to support the deficiency diagnosis, leading to audit denials and compliance issues. CDI opportunity.
Incorrectly coding Vitamin D deficiency as Osteomalacia or Rickets (E55.0, E55.2) without proper documentation, causing overcoding and compliance risks.
Patient presents with complaints consistent with vitamin D deficiency, including fatigue, muscle weakness, bone pain, and depressed mood. Symptoms onset reported as gradual over the past several months. Patient denies any history of malabsorption syndromes, renal disease, or liver disease. Dietary intake of vitamin D rich foods reported as low. Limited sun exposure due to work schedule and lifestyle. Physical examination reveals tenderness to palpation in the lower back and legs. Laboratory results confirm vitamin D deficiency with a 25-hydroxyvitamin D level of 15 ngmL. Diagnosis of vitamin D deficiency confirmed based on patient symptoms, physical exam findings, and laboratory results. Differential diagnoses considered included hypothyroidism, fibromyalgia, and osteoporosis. Plan includes initiating vitamin D supplementation with cholecalciferol 50,000 IU weekly for 8 weeks, followed by maintenance therapy of 1,000-2,000 IU daily. Patient education provided on importance of vitamin D for bone health, muscle function, and overall well-being. Counseling also provided regarding dietary sources of vitamin D and increasing sun exposure safely. Follow-up appointment scheduled in 8 weeks to reassess symptoms and monitor 25-hydroxyvitamin D levels. ICD-10 code E55.9 Vitamin D deficiency, unspecified assigned. CPT codes for laboratory testing and office visit documented.