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2025 ICD-10-CM code T45.4X6S

Underdosing of iron and its compounds, sequela

Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate the cause of the initial underdosing. Code first, the nature of the sequela, such as anemia (D50-D64). Excludes1: iron deficiency (E61.1)

The medical necessity should be established by documenting the direct link between the underdosing of iron and the patient's current health status. The documentation must clearly indicate that the sequelae are a direct result of the insufficient iron intake, necessitating further medical intervention.

IMPORTANT T45.4X6 (Underdosing of iron and its compounds, initial encounter)

In simple words: This code signifies the lasting effects due to previously insufficient intake of iron supplements or iron-containing medications.

This code represents the long-term consequences resulting from an insufficient dosage of iron or iron compounds. It indicates that the patient is experiencing ongoing health issues as a direct result of the past underdosing.

Example 1: A patient with a history of iron deficiency anemia, treated with iron supplements, presents with persistent fatigue and pallor. Lab results reveal low hemoglobin levels, indicating ongoing anemia due to previous inadequate iron supplementation. T45.4X6S is used to code the sequela of the underdosing., A patient who unintentionally took fewer iron pills than prescribed over several months develops symptoms like shortness of breath and dizziness. Diagnosis confirms iron deficiency anemia resulting from chronic underdosing. T45.4X6S is applied due to the ongoing nature of the condition., A patient with chronic kidney disease requiring iron injections receives insufficient doses due to a medication error. Over time, the patient experiences worsening anemia and requires blood transfusions. Code T45.4X6S reflects the long-term consequences of the underdosing incident.

Documentation should support the causal relationship between the underdosing of iron and its compounds and the current condition of the patient. This includes details about the initial underdosing event, duration, and the manifested sequelae. Include relevant lab results, clinical findings, and treatment history.

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