ICD-10 Coding for Thyroid Enlargement(E04.9, E04.2)
Complete ICD-10-CM coding and documentation guide for Thyroid Enlargement. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Thyroid Enlargement
E04-E05Primary Range
Disorders of thyroid gland
This range includes codes for various types of goiter, both toxic and non-toxic, which are relevant for documenting thyroid enlargement.
Thyroiditis
This range is relevant for conditions where thyroiditis is the underlying cause of thyroid enlargement.
Other disorders of thyroid
Includes conditions like dyshormonogenesis that can lead to thyroid enlargement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E04.9 | Nontoxic goiter, unspecified | Use when the type of goiter is not specified and thyroid function is normal. |
|
| E04.2 | Nontoxic multinodular goiter | Use when multiple nodules are confirmed and thyroid function is normal. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for thyroid enlargement
Essential facts and insights about Thyroid Enlargement
Primary ICD-10-CM Codes for thyroid enlargement
Decision Criteria
clinical Criteria
- Thyroid enlargement without symptoms of hyperthyroidism
Applicable To
- Enlarged thyroid
- Simple goiter
Excludes
- Toxic goiter (E05.-)
Clinical Validation Requirements
- Physical exam showing thyroid enlargement
- Normal thyroid function tests
Code-Specific Risks
- Overuse when more specific codes apply
Coding Notes
- Ensure documentation specifies the type of goiter if known.
E04.2 - Nontoxic multinodular goiter
Use when multiple nodules are confirmed and thyroid function is normal.
Applicable To
- Multinodular goiter
Excludes
- Toxic multinodular goiter (E05.2)
Clinical Validation Requirements
- Ultrasound showing multiple nodules
- Normal thyroid function tests
Coding Notes
Document the presence of nodules and normal thyroid function.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Thyroid Enlargement to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E04.9.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Ensure detailed examination and imaging results are documented, Use specific terminology for nodularity
Impact
Reimbursement: May result in lower reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use E04.2 for multinodular goiter if nodules are confirmed.
Impact
Risk of audits due to non-specific coding of thyroid enlargement.
Mitigation Strategy
Ensure documentation includes specific details about nodularity and thyroid function.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Thyroid Enlargement, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Thyroid Enlargement
Use these documentation templates to ensure complete and accurate documentation for Thyroid Enlargement. These templates include all required elements for proper coding and billing.
Routine Examination with Thyroid Enlargement
Specialty: EndocrinologyRequired Elements
- Patient history
- Physical examination findings
- Laboratory results
- Imaging studies
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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