ICD-10 Coding for Abnormal Thyroid Function Test(R94.6, E03.9)
Complete ICD-10-CM coding and documentation guide for Abnormal Thyroid Function Test. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Thyroid Function Test
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R94.6 | Abnormal results of thyroid function studies | Use when thyroid function tests are abnormal but no specific thyroid disorder is diagnosed. |
|
| E03.9 | Hypothyroidism, unspecified | Use when hypothyroidism is confirmed but not specified. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal thyroid function test
Essential facts and insights about Abnormal Thyroid Function Test
Primary ICD-10-CM Codes for abnormal thyroid function test
Decision Criteria
clinical Criteria
- Abnormal TSH or T4 levels without a specific diagnosis.
coding Criteria
- No specific thyroid disorder code applicable.
Applicable To
- Abnormal TSH
- Abnormal T4
- Abnormal T3
Excludes
- Specific thyroid disorders (E00-E07)
Clinical Validation Requirements
- TSH outside 0.4-4.0 mIU/L
- Free T4 outside 0.8-1.8 ng/dL
Code-Specific Risks
- Using R94.6 when a specific thyroid disorder is confirmed.
Coding Notes
- R94.6 should not be used if a specific thyroid disorder is diagnosed.
E03.9 - Hypothyroidism, unspecified
Use when hypothyroidism is confirmed but not specified.
Applicable To
- Primary hypothyroidism
Excludes
- Congenital hypothyroidism (E03.0)
Clinical Validation Requirements
- TSH >4.5 mIU/L
- Free T4 <0.8 ng/dL
Coding Notes
Ensure hypothyroidism is confirmed before using E03.9.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other fatigue
R53.83Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Thyroid Function Test to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R94.6.
Impact
Clinical: Incomplete clinical picture., Regulatory: Potential for claim denial., Financial: Loss of reimbursement.
Mitigation Strategy
Always document symptoms alongside lab results.
Impact
Reimbursement: Claims may be denied if R94.6 is used incorrectly., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use the specific thyroid disorder code instead.
Impact
Claims may be audited if R94.6 is used without documented follow-up plan.
Mitigation Strategy
Ensure follow-up plans are documented when using R94.6.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Thyroid Function Test, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Thyroid Function Test
Use these documentation templates to ensure complete and accurate documentation for Abnormal Thyroid Function Test. These templates include all required elements for proper coding and billing.
Abnormal thyroid function test with symptoms
Specialty: EndocrinologyRequired Elements
- Patient symptoms
- Specific abnormal lab values
- Clinical interpretation
- Plan for follow-up
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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