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
Persons with potential health hazards
History of prior surgical procedures affecting health status.
Endocrine, nutritional, and metabolic diseases
Covers post-surgical complications of endocrine disorders.
Postprocedural endocrine and metabolic complications
Specific codes for complications following endocrine procedures.
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)
Coding lacks specificity regarding current thyroid status (e.g., total/partial removal, complications).
Underlying reason for thyroidectomy (e.g., cancer, goiter) is not documented or coded, affecting risk adjustment.
Thyroidectomy date is inconsistent across records, impacting accurate coding and clinical timelines.
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.