Find comprehensive information on thyromegaly, including clinical documentation tips, ICD-10 codes (E04.9, E04.8, E04.0 - E04.2 depending on underlying cause), SNOMED CT codes, and medical coding guidelines. Learn about goiter diagnosis, symptoms, differential diagnosis, and treatment options. Explore resources for healthcare professionals, including coding best practices for enlarged thyroid and thyroid gland enlargement documentation in electronic health records. This resource provides valuable insights for accurate and efficient medical coding and documentation related to thyromegaly.
Also known as
Thyroid disorders
Thyromegaly, unspecified
Thyroid disorders
Disorders of thyroid gland function and growth.
Iodine deficiency
Thyromegaly can be associated with iodine deficiency.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the thyromegaly due to a specific underlying condition?
Yes
Is it due to Graves disease?
No
Is it simple or nontoxic?
When to use each related code
| Description |
|---|
| Enlarged thyroid gland |
| Goiter, unspecified |
| Nodular goiter |
Coding unspecified thyromegaly (E04.9) without documenting underlying cause risks downcoding and lost revenue. CDI should query for specificity.
Failing to code associated goiter (E04.0-E04.2) with thyromegaly when present leads to inaccurate reporting and impacts quality metrics.
Incorrectly coding thyromegaly as thyroiditis or vice-versa based on incomplete documentation can lead to coding errors and compliance issues.
Patient presents with complaints suggestive of thyromegaly, including enlarged thyroid gland, neck swelling, or symptoms related to compression such as dysphagia, dyspnea, or hoarseness. Physical examination reveals a palpable goiter, with or without associated nodules. Thyroid size, consistency, and symmetry are documented. Assessment includes evaluation for thyroid function abnormalities with thyroid stimulating hormone (TSH), free T4, and free T3 levels. Differential diagnosis includes Graves disease, Hashimoto thyroiditis, thyroid nodules, thyroid cancer, and iodine deficiency. Further investigation may include thyroid ultrasound, radioactive iodine uptake scan, or fine needle aspiration biopsy depending on clinical suspicion. Treatment plan is dependent on underlying etiology and may include observation, medical management with thyroid hormone replacement or antithyroid medications, or surgical intervention such as thyroidectomy. Patient education regarding the diagnosis, potential complications, and treatment options is provided. ICD-10 code E04.9, unspecified nontoxic goiter, or other appropriate codes based on etiology, is considered for medical billing and coding purposes. Follow-up is scheduled to monitor thyroid function and size, and to assess response to treatment.