ICD-10 Coding for Abnormal Thyroid Lab(R94.6, E03.9)
Complete ICD-10-CM coding and documentation guide for Abnormal Thyroid Lab. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Thyroid Lab
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 by lab results. |
|
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 labs
Essential facts and insights about Abnormal Thyroid Lab
Primary ICD-10-CM Codes for abnormal thyroid lab
Decision Criteria
clinical Criteria
- Abnormal TSH or T4 without a specific thyroid disorder diagnosis
coding Criteria
- Avoid using R94.6 as primary if E03.x or E05.x is applicable
Clinical Validation Requirements
- Documented abnormal TSH or T4 without a definitive thyroid disorder diagnosis
Code-Specific Risks
- Improper use as a primary diagnosis when a definitive condition is present
Coding Notes
- R94.6 should not be used as a primary diagnosis if a specific thyroid disorder is identified.
E03.9 - Hypothyroidism, unspecified
Use when hypothyroidism is confirmed by lab results.
Applicable To
- Primary hypothyroidism
Excludes
- Congenital hypothyroidism (E03.0)
Clinical Validation Requirements
- Elevated TSH >5 mIU/L
- Low free T4
Coding Notes
Ensure lab results confirm hypothyroidism before coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for screening for other suspected endocrine disorder
Z13.29Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Thyroid Lab to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R94.6.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always include lab results in documentation., Ensure clinical correlation is noted.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of medical records.
Mitigation Strategy
Use specific thyroid disorder codes like E03.9 or E05.90 when applicable.
Impact
R94.6 used without supporting lab results.
Mitigation Strategy
Ensure all lab results are documented in the patient's record.
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 Lab, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Thyroid Lab
Use these documentation templates to ensure complete and accurate documentation for Abnormal Thyroid Lab. These templates include all required elements for proper coding and billing.
Abnormal Thyroid Lab Results
Specialty: EndocrinologyRequired Elements
- Patient symptoms
- TSH and T4 levels
- Clinical correlation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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