ICD-10 Coding for Thyromegaly(E04.9, E04.2)
Complete ICD-10-CM coding and documentation guide for Thyromegaly. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Thyromegaly
E04-E07Primary Range
Disorders of thyroid gland
This range includes codes for various types of goiter and thyroid disorders, which encompass thyromegaly.
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 thyroid is enlarged without specific nodularity or functional abnormalities. |
|
| E04.2 | Nontoxic multinodular goiter | Use when multiple nodules are present 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 thyromegaly
Essential facts and insights about Thyromegaly
Primary ICD-10-CM Codes for thyromegaly
Decision Criteria
clinical Criteria
- Thyroid enlargement without nodules or functional changes
Applicable To
- Enlarged thyroid without nodularity or functional status
Excludes
- Toxic goiter (E05.-)
Clinical Validation Requirements
- Physical examination showing thyroid enlargement
- Normal thyroid function tests
Code-Specific Risks
- Overuse when more specific codes are applicable
Coding Notes
- Ensure documentation specifies the absence of nodularity or functional changes.
E04.2 - Nontoxic multinodular goiter
Use when multiple nodules are present and thyroid function is normal.
Applicable To
- Multinodular thyroid enlargement with normal function
Excludes
- Toxic multinodular goiter (E05.2-)
Clinical Validation Requirements
- Ultrasound showing multiple nodules
- Normal TSH levels
Coding Notes
Document the number and size of nodules.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Thyromegaly to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E04.9.
Impact
Clinical: Inaccurate diagnosis and treatment, Regulatory: Non-compliance with coding guidelines, Financial: Potential reimbursement issues
Mitigation Strategy
Ensure all thyroid function tests are ordered and results documented
Impact
Reimbursement: Potential underpayment due to lack of specificity, Compliance: Increased audit risk, Data Quality: Decreased accuracy in clinical data
Mitigation Strategy
Use E04.2 if nodules are present
Impact
High audit risk due to lack of specificity in coding.
Mitigation Strategy
Use specific codes like E04.2 when documentation supports it.
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 Thyromegaly, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Thyromegaly
Use these documentation templates to ensure complete and accurate documentation for Thyromegaly. These templates include all required elements for proper coding and billing.
Patient with thyroid enlargement and nodules
Specialty: EndocrinologyRequired Elements
- Thyroid size and symmetry
- Presence and size of nodules
- Thyroid function test results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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