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Z90.2
ICD-10-CM
History of Thyroidectomy

Find comprehensive information on coding and documenting a history of thyroidectomy. This resource covers relevant ICD-10 codes, SNOMED CT concepts, clinical documentation improvement tips for thyroidectomy status post, postoperative complications, and best practices for accurate medical record keeping. Learn about total thyroidectomy, partial thyroidectomy, and the implications for patient care and medical coding. Explore resources for healthcare professionals, including physicians, coders, and clinical documentation specialists.

Also known as

Post-Thyroidectomy Status
Thyroid Removal History

Diagnosis Snapshot

Key Facts
  • Definition : Surgical removal of all or part of the thyroid gland.
  • Clinical Signs : Depending on extent of surgery: Hypothyroidism, neck swelling, voice changes, difficulty swallowing.
  • Common Settings : Hospital operating room, outpatient surgical center.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z90.2 Coding
Z90-Z99

Persons with potential health hazards

History of prior surgical procedures affecting health status.

E00-E89

Endocrine, nutritional, and metabolic diseases

Covers post-surgical complications of endocrine disorders.

E89

Postprocedural endocrine and metabolic complications

Specific codes for complications following endocrine procedures.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Any complications or sequelae?

  • Yes

    Specify the complication

  • No

    Code Z90.89 (Acquired absence of thyroid)

Documentation Best Practices

Documentation Checklist
  • Thyroidectomy date documented
  • Thyroidectomy type specified (e.g., partial, total)
  • Original indication for thyroidectomy clearly stated
  • Postoperative complications, if any, noted
  • Current thyroid hormone replacement status

Coding and Audit Risks

Common Risks
  • Unspecified Status

    Coding lacks specificity regarding current thyroid status (e.g., total/partial removal, complications).

  • Missing Indication

    Underlying reason for thyroidectomy (e.g., cancer, goiter) is not documented or coded, affecting risk adjustment.

  • Date Discrepancy

    Thyroidectomy date is inconsistent across records, impacting accurate coding and clinical timelines.

Mitigation Tips

Best Practices
  • Document thyroidectomy type, date, & reason.
  • Specify partial vs. total, & laterality.
  • Code to highest specificity; use Z90.89.
  • Query physician for unclear documentation.
  • Check for related diagnoses: hypo/hyperthyroidism.

Clinical Decision Support

Checklist
  • Confirm thyroidectomy type (partial/total). Code to Z90.89
  • Document surgical details, date, & reason. ICD-10-PCS validation
  • Check for current thyroid hormone replacement therapy. SNOMED CT review
  • Assess for complications (hypocalcemia, nerve damage). Patient safety
  • Review operative report for confirmation. Improve documentation quality

Reimbursement and Quality Metrics

Impact Summary
  • Thyroidectomy history coding impacts reimbursement for subsequent visits related to thyroid disorders, influencing payment accuracy.
  • Accurate History of Thyroidectomy diagnosis coding improves quality reporting metrics related to thyroid disease management.
  • Proper coding for History of Thyroidectomy impacts hospital data analysis for patient outcomes and resource allocation.
  • Specific ICD-10 codes for thyroidectomy history affect case mix index (CMI) and subsequent hospital reimbursement levels.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code Z90.89 for thyroidectomy history
  • Document type/extent of thyroidectomy
  • Specify reason for thyroidectomy
  • Look for complications, code if present
  • Query physician if documentation unclear

Documentation Templates

Patient presents with a history of thyroidectomy.  The surgical procedure date was documented as [Date of Thyroidectomy] and performed by [Surgeon Name or N/A if unknown].  The indication for the thyroidectomy was [Indication for surgery e.g., papillary thyroid cancer, Graves' disease, multinodular goiter, toxic adenoma].  The operative report indicates a [Type of thyroidectomy e.g., total thyroidectomy, subtotal thyroidectomy, lobectomy, completion thyroidectomy] was performed.  Post-surgical pathology confirmed the diagnosis of [Pathology Diagnosis e.g., papillary thyroid carcinoma, follicular adenoma].  Current medications include [List current medications including thyroid hormone replacement if applicable e.g., levothyroxine, liothyronine]. The patient reports [Symptoms if any e.g., no symptoms, fatigue, cold intolerance, hoarseness, dysphagia].  Physical examination of the neck reveals a well-healed surgical scar.  [Presence or absence of palpable thyroid tissue].  Current thyroid function tests (TFTs) show [TSH, Free T4, Free T3 levels and interpretation e.g., within normal limits, suppressed TSH, elevated TSH].  The patient is currently [Status of thyroid hormone replacement e.g., euthyroid on levothyroxine, hypothyroid, requires dose adjustment].  Plan includes continued monitoring of TFTs and [Follow-up plan e.g., annual neck ultrasound, thyroglobulin measurement, referral to endocrinology]. This documentation supports the diagnosis of history of thyroidectomy with relevant clinical findings and management plan.
History of Thyroidectomy - AI-Powered ICD-10 Documentation