Celiac Disease Documentation Guide
Autoimmune enteropathy triggered by gluten ingestion causing villous atrophy and malabsorption.
ICD-10 Codes: K90.0
Common Symptoms
- Chronic diarrhea
- Bloating
- Weight loss
- Iron deficiency anemia
- Fatigue
Key Documentation Elements
- Serologic testing results (tTG-IgA, EMA, DGP)
- Duodenal biopsy Marsh classification
- Gluten-free diet adherence assessment
- Nutritional deficiency screening (iron, B12, folate, vitamin D)
- Associated condition monitoring (bone density, thyroid)
Documentation Challenges
- Documenting serologic testing (tTG-IgA) and biopsy results
- Recording Marsh classification of duodenal histology
- Capturing dietary compliance assessment and nutritional status
- Tracking associated conditions (dermatitis herpetiformis, osteoporosis)
Billing Considerations
- K90.0 with linked nutritional deficiency codes
- Endoscopy and biopsy procedure coding
- Chronic disease management for ongoing monitoring
Frequently Asked Questions
What documentation is needed for celiac disease diagnosis?
Celiac diagnosis requires documenting serologic testing (tTG-IgA positive), confirmatory duodenal biopsy with Marsh classification, and clinical response to gluten-free diet. Scribeable captures all diagnostic criteria.
How does Scribeable support celiac disease follow-up?
Scribeable records dietary compliance assessment, repeat serology trends, nutritional deficiency screening, and associated condition monitoring from your encounters for comprehensive follow-up documentation.