Find information on thyroid screening, including TSH tests, thyroid ultrasound, and fine needle aspiration biopsy. Learn about relevant medical coding (ICD-10 codes for thyroid disorders like hypothyroidism and hyperthyroidism) and clinical documentation requirements for accurate diagnosis and billing. Explore resources for healthcare professionals on thyroid function tests, thyroid nodules, goiter, and thyroid cancer screening. Understand the importance of early detection and proper management of thyroid conditions.
Also known as
Encounter for screening for oth. dis
Screening for diseases other than endocrine.
Endocrine, nutritional, metabolic
Covers endocrine disorders like thyroid issues.
Factors influencing health status
Includes general health examinations and screenings.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the screening due to personal/family history or other high risk?
When to use each related code
| Description |
|---|
| Thyroid Screening |
| Hypothyroidism |
| Hyperthyroidism |
Coding with unspecified screening codes (e.g., Z13.89) when more specific thyroid screening diagnosis codes are applicable, leading to inaccurate risk adjustment.
Failing to capture and code relevant family history of thyroid disease (e.g., Z83.4) which impacts risk adjustment and care management.
Incorrectly coding screening encounters as incident-to when they should be billed under the ordering physician, resulting in compliance violations.
Patient presented for thyroid screening due to family history of hypothyroidism and symptoms suggestive of thyroid dysfunction, including fatigue, weight gain, and constipation. Patient reports increased sensitivity to cold and dry skin. Physical examination revealed no palpable thyroid nodules or goiter. Vital signs were within normal limits. Assessment includes thyroid stimulating hormone (TSH) blood test ordered to evaluate thyroid function and screen for hypothyroidism or hyperthyroidism. Differential diagnoses include subclinical hypothyroidism, Hashimoto's thyroiditis, and iodine deficiency. Plan includes review of TSH results and correlation with patient symptoms. If TSH is abnormal, further evaluation with free T4 and thyroid peroxidase antibodies (TPO antibodies) will be considered. Patient education provided on thyroid disorders, including signs and symptoms, risk factors, and treatment options. Follow-up appointment scheduled to discuss results and determine appropriate management plan, which may include thyroid hormone replacement therapy if indicated. Medical coding may include ICD-10 codes for screening for thyroid disorders (Z13.89) and related symptoms, such as fatigue (R53.83) and constipation (R19.4). Billing codes will reflect the evaluation and management (E/M) services provided, along with laboratory testing for TSH.