2025 ICD-10-CM code T45.4X6

Underdosing of iron and its compounds.

Code first the nature of the adverse effect (if any). Use additional codes to identify any retained foreign body, if applicable (Z18.-).Note that iron deficiency itself (E61.1) is excluded.

Medical necessity for iron supplementation is established when a patient has an iron deficiency resulting in anemia or other clinical manifestations. The underdosing leading to inadequate treatment response, is a deviation from the appropriate use, rendering the procedure medically necessary to correct the resulting deficiency.

The clinical responsibility for coding T45.4X6 lies with the physician or healthcare provider who manages the patient's iron supplementation and identifies the underdosing. This includes monitoring the patient's response to treatment, adjusting the dosage as needed, and documenting the reason for the underdosing.

IMPORTANT Consider using additional codes to specify manifestations of poisoning, underdosing, or failure in dosage during medical or surgical care (Y63.6, Y63.8-Y63.9). Also, underdosing of a medication regimen may require codes from Z91.12- and Z91.13-.Iron deficiency (E61.1) is excluded.

In simple words: This code is used when someone takes too little iron medicine.It means they didn't get enough iron to help their health problem.

This code classifies the underdosing of iron and its compounds.It is used when the administered dose of iron or its compounds is insufficient to achieve the desired therapeutic effect.This should be distinguished from iron deficiency, which is a separate diagnostic entity.

Example 1: A patient with iron-deficiency anemia is prescribed an iron supplement. Due to unintentional non-compliance (e.g., forgetting doses), the patient does not take the prescribed amount, leading to inadequate iron levels and persistent anemia.Code T45.4X6 is used to describe the underdosing., A physician unintentionally prescribes a lower-than-recommended dose of iron to a patient with iron-deficiency anemia due to a calculation error. The insufficient dose results in suboptimal treatment response. Code T45.4X6 is used in this case of underdosing., A patient with anemia, prescribed iron supplements, experiences gastrointestinal side effects after taking the prescribed dose. The patient, then, voluntarily reduces the dose. This self-adjusting lowers the effective dose of iron. The subsequent inadequate treatment response would warrant T45.4X6.

Documentation must include the prescribed dose of iron, the actual dose taken by the patient, the reason for the underdosing (intentional or unintentional), and evidence of inadequate response to treatment.Lab results (e.g., ferritin levels, hemoglobin levels) should support the diagnosis.Medical records must include the provider's assessment of the patient's clinical status and rationale for treatment.

** This code is primarily used in cases where underdosing is the direct result of an error in medication administration, or patient non-compliance.It's important to distinguish between underdosing (T45.4X6) and the underlying condition of iron deficiency (E61.1).

  • Payment Status: Active
  • Specialties:Hematology, Gastroenterology, Internal Medicine
  • Place of Service:Office, Hospital Inpatient, Hospital Outpatient
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