Find comprehensive information on Thyroid Stimulating Hormone (TSH) diagnosis including clinical documentation, medical coding, and healthcare guidelines. Learn about TSH levels, TSH test interpretation, hypothyroidism, hyperthyroidism, thyroid disorders, and relevant ICD-10 codes. This resource provides valuable information for healthcare professionals, clinicians, and medical coders seeking accurate and up-to-date information on TSH diagnosis and management.
Also known as
Endocrine, nutritional and metabolic diseases
Covers disorders of glands and metabolism, including thyroid issues.
Thyroid disorders
Specifically relates to various thyroid dysfunctions like hyper and hypothyroidism.
Other hypothyroidism
Includes specific types of hypothyroidism not due to iodine deficiency.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the TSH level abnormal?
Yes
Is TSH elevated?
No
No specific ICD-10-CM code for normal TSH.
When to use each related code
| Description |
|---|
| Elevated TSH |
| Suppressed TSH |
| Normal TSH, abnormal T4 |
Incorrect TSH code selection (e.g., total vs. free T3/T4) impacting reimbursement and data accuracy. Relevant for medical coding, CDI, and healthcare compliance.
Missing or inadequate documentation of TSH levels and related findings leading to coding errors and audit denials. Critical for CDI and healthcare compliance.
Coding TSH without correlating diagnosis (e.g., hypothyroidism, hyperthyroidism) risking compliance issues and affecting quality metrics. Important for medical coding and CDI.
Patient presents with symptoms suggestive of thyroid dysfunction, prompting evaluation of thyroid stimulating hormone (TSH) levels. Symptoms include fatigue, weight changes, constipation or diarrhea, changes in hair texture or skin, menstrual irregularities, and mood changes such as depression or anxiety. Physical examination may reveal goiter, bradycardia or tachycardia, tremor, changes in reflexes, and skin changes. Differential diagnosis includes hypothyroidism, hyperthyroidism, subclinical hypothyroidism, subclinical hyperthyroidism, thyroiditis, and pituitary disorders affecting TSH secretion. Laboratory testing ordered includes TSH, free T4 (thyroxine), and free T3 (triiodothyronine) levels. TSH level is [insert value and units], which, in conjunction with [free T4 and free T3 levels, if applicable], suggests [diagnosis, e.g., primary hypothyroidism, subclinical hyperthyroidism, euthyroid sick syndrome]. Medical decision making includes consideration of patient's age, comorbidities, medication list, and symptom severity. Treatment plan may include thyroid hormone replacement therapy (levothyroxine), antithyroid medications (methimazole, propylthiouracil), radioactive iodine therapy, or watchful waiting with repeat testing. Patient education provided regarding the diagnosis, treatment options, potential side effects of medications, and importance of medication adherence. Follow-up appointment scheduled to monitor treatment response and adjust medication dosage as needed. ICD-10 code[s] [insert appropriate code(s) e.g., E03.9, E05.9] and CPT code[s] [insert appropriate code(s), e.g., 84443] documented for billing and coding purposes.