ICD-10 Coding for Thyroidectomy(E05.10, Z48.3)
Complete ICD-10-CM coding and documentation guide for Thyroidectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Thyroidectomy
E00-E07Primary Range
Disorders of thyroid gland
This range includes all disorders related to the thyroid gland, which are relevant for pre- and post-thyroidectomy conditions.
Aftercare and follow-up
This range includes codes for aftercare following surgery, relevant for post-thyroidectomy follow-up.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E05.10 | Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm | Use when a patient presents with a toxic single thyroid nodule confirmed by lab and imaging studies. |
|
| Z48.3 | Aftercare following surgery for neoplasm | Use for follow-up visits after thyroidectomy for neoplasm. |
|
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 thyroidectomy
Essential facts and insights about Thyroidectomy
Primary ICD-10-CM Codes for thyroidectomy
Decision Criteria
clinical Criteria
- Presence of a toxic nodule with suppressed TSH levels
documentation Criteria
- Documented evidence of hyperthyroidism and nodule size
Applicable To
- Toxic single thyroid nodule
Excludes
- Thyrotoxic crisis or storm (E05.01)
Clinical Validation Requirements
- TSH <0.4 μIU/mL
- Nodule ≥1cm on ultrasound
- Radioactive iodine uptake scan showing hyperfunctioning nodule
Code-Specific Risks
- Misclassification if hyperthyroidism is not documented
- Incorrect use if nodule is non-toxic
Coding Notes
- Ensure biochemical confirmation of hyperthyroidism is documented.
Z48.3 - Aftercare following surgery for neoplasm
Use for follow-up visits after thyroidectomy for neoplasm.
Applicable To
- Follow-up care after surgery for cancer
Excludes
- Aftercare following surgery for other conditions (Z48.0-Z48.2)
Clinical Validation Requirements
- Post-operative status documented
- Surgical site healing and follow-up care
Coding Notes
Ensure the surgery was specifically for a neoplasm.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of malignant neoplasm of thyroid
Z85.850Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Thyroidectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E05.10.
Impact
Clinical: Inaccurate surgical history in patient records., Regulatory: Potential audit issues due to incomplete documentation., Financial: Denied claims due to incorrect coding.
Mitigation Strategy
Review prior surgical history before coding., Ensure operative notes include details of previous surgeries.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate surgical data in patient records.
Mitigation Strategy
Use 60260 for completion thyroidectomy, ensuring prior surgery is documented.
Impact
Lack of detailed operative notes can lead to coding errors.
Mitigation Strategy
Implement a checklist for operative notes to ensure all required elements are documented.
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 Thyroidectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Thyroidectomy
Use these documentation templates to ensure complete and accurate documentation for Thyroidectomy. These templates include all required elements for proper coding and billing.
Total thyroidectomy with malignancy
Specialty: Endocrine SurgeryRequired Elements
- Pre-op diagnosis
- Procedure details
- Findings
- Technique
- Specimens sent
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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