Find information on documenting and coding a personal history of thyroid cancer. This resource covers clinical documentation requirements, ICD-10 codes (Z85.850), SNOMED CT concepts, and best practices for accurately recording a patient's past thyroid cancer diagnosis in healthcare settings. Learn about the importance of complete medical history documentation for optimal patient care and appropriate billing. Explore resources for healthcare professionals related to past thyroid malignancy, history of thyroid carcinoma, and previous thyroid cancer treatment.
Also known as
Personal history of thyroid cancer
Indicates a past diagnosis of thyroid cancer, now inactive.
Personal history of other malignant neoplasms
History of other cancers not otherwise specified, including thyroid if not Z85.820.
Postprocedural hypothyroidism
Low thyroid function following procedures, sometimes related to prior thyroid cancer treatment.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the thyroid cancer currently active?
Yes
Do NOT code as personal history. Code the active thyroid cancer (C73.-).
No
Is there any evidence of recurrence or residual tumor?
When to use each related code
Description |
---|
Personal history of thyroid cancer |
History of thyroid nodule |
Family history of thyroid cancer |
Lack of specific Z85 codes for thyroid cancer history, leading to inaccurate coding of laterality, histology, and treatment status.
Miscoding active thyroid cancer (C73) as personal history (Z85) impacting treatment and surveillance planning.
Insufficient documentation of complete thyroid cancer history (type, treatment, laterality) hindering accurate code assignment.
Patient presents with a personal history of thyroid cancer. Initial diagnosis of (specify thyroid cancer type, e.g., papillary, follicular, medullary, anaplastic) thyroid carcinoma was established on (date) based on (diagnostic methods, e.g., fine-needle aspiration biopsy, thyroidectomy pathology). The original tumor size was (size) cm, located in the (location, e.g., right lobe, left lobe, isthmus). (Specify if multifocal or multicentric). Staging at diagnosis was (TNM stage). Initial treatment included (surgical procedures, e.g., total thyroidectomy, lobectomy, isthmusectomy, lymph node dissection) performed on (date). Post-surgical radioactive iodine therapy (RAI) was (administered or not administered) with (dosage and date if applicable). Thyroid stimulating hormone (TSH) suppression therapy with (medication name and dosage) was initiated. Current TSH level is (value) mU/L. Patient is currently (asymptomatic or symptomatic, specifying symptoms if present). Physical examination of the neck reveals (findings, e.g., no palpable masses, surgical scar). Surveillance includes (ongoing monitoring plan, e.g., periodic TSH levels, neck ultrasound, thyroglobulin measurements). Assessment: History of (thyroid cancer type) thyroid cancer, status post (treatment summary). Plan: Continue current management with (medication and dosage) and scheduled follow-up in (timeframe) for (purpose of follow-up, e.g., TSH monitoring, physical exam, ultrasound). Differential diagnoses at initial presentation included (list relevant differential diagnoses). ICD-10 code: (appropriate ICD-10 code, e.g., Z85.850). This documentation supports medical necessity for continued surveillance and management of the patient's history of thyroid cancer.