What is the ICD-10 (International Classification of Diseases, 10th Revision) code for Vitamin D deficiency?

ICD-10 Code for Vitamin D Deficiency

The ICD-10 code for Vitamin D deficiency is E55.9. This is the appropriate diagnostic code to use when documenting vitamin D deficiency in medical records and for billing purposes.

Types of Vitamin D Deficiency Codes

Vitamin D deficiency can be coded more specifically depending on the clinical manifestations:

• E55.0: Rickets, active (vitamin D deficiency rickets)
• E55.9: Vitamin D deficiency, unspecified (without manifestations)
• E64.3: Sequelae of rickets (late effects of rickets)

Clinical Definition of Vitamin D Deficiency

When documenting vitamin D deficiency, it's important to understand the clinical definitions:

• Vitamin D deficiency: Serum 25-hydroxyvitamin D (25-OHD) level < 20 ng/mL (50 nmol/L) 1, 2
• Vitamin D insufficiency: Serum 25-OHD level 20-30 ng/mL (50-75 nmol/L) 1, 2
• Severe vitamin D deficiency: Serum 25-OHD level < 30 nmol/L (12 ng/mL) 3

Clinical Manifestations to Document

For proper coding, document relevant clinical manifestations that may be associated with vitamin D deficiency:

• Symmetric low back pain
• Proximal muscle weakness
• Muscle aches
• Throbbing bone pain (especially when pressure is applied over sternum or tibia) 2
• Increased risk of fractures
• Secondary hyperparathyroidism 1
• Osteomalacia in adults or rickets in children (for more severe cases) 1

Laboratory Documentation

Include the following laboratory values in your documentation to support the diagnosis:

• 25-hydroxyvitamin D (25-OHD) level (the gold standard test) 1
• Corrected serum calcium and serum phosphate (if abnormal) 4
• Parathyroid hormone levels (if secondary hyperparathyroidism is suspected) 4

Common Pitfalls in Coding

1. Using incorrect specificity: Using the general code (E55.9) when manifestations like rickets are present (should use E55.0)

2. Failure to document severity: Not specifying whether the condition is deficiency (<20 ng/mL) or insufficiency (20-30 ng/mL)

3. Missing associated conditions: Not documenting conditions that may be causing or resulting from vitamin D deficiency, which may require additional codes

4. Overlooking inflammation: CRP levels can affect vitamin D measurements - CRP >40 mg/L can lead to falsely low vitamin D readings 4

5. Not considering risk factors: Failing to document risk factors like limited sun exposure, darker skin pigmentation, advanced age, obesity, malabsorption, or severe liver/kidney disease 1

Remember that proper documentation of vitamin D status, clinical manifestations, and treatment plan helps justify the medical necessity of vitamin D testing and supplementation for insurance coverage purposes.