ICD-10 Coding for Abnormal Thyroid Stimulating Hormone(R94.6, E03.9)
Complete ICD-10-CM coding and documentation guide for Abnormal Thyroid Stimulating Hormone. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Thyroid Stimulating Hormone
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 TSH is abnormal but no specific thyroid disorder is diagnosed. |
|
| E03.9 | Hypothyroidism, unspecified | Use when hypothyroidism is confirmed with clinical symptoms and 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 TSH
Essential facts and insights about Abnormal Thyroid Stimulating Hormone
Primary ICD-10-CM Codes for abnormal thyroid stimulating hormone
Decision Criteria
clinical Criteria
- TSH level outside normal range without specific thyroid disorder diagnosis
Applicable To
- Abnormal TSH levels
Excludes
- Specific thyroid disorders (E00-E07)
Clinical Validation Requirements
- Documented TSH level outside the normal reference range
- Absence of a confirmed thyroid disorder diagnosis
Code-Specific Risks
- Using R94.6 when a specific thyroid disorder is diagnosed
Coding Notes
- Ensure TSH values and reference ranges are documented.
E03.9 - Hypothyroidism, unspecified
Use when hypothyroidism is confirmed with clinical symptoms and lab results.
Applicable To
- Primary hypothyroidism
Excludes
- Congenital hypothyroidism (E03.0)
Clinical Validation Requirements
- Elevated TSH with low free T4
- Symptoms such as fatigue, weight gain
Coding Notes
Document both TSH and free T4 levels.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Stimulating Hormone 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 inappropriate treatment decisions., Regulatory: Could result in audit findings., Financial: Potential claim denials due to lack of medical necessity.
Mitigation Strategy
Always document symptoms when ordering TSH tests., Ensure lab results are accompanied by clinical context.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and statistics.
Mitigation Strategy
Use the specific thyroid disorder code, such as E03.9 for hypothyroidism.
Impact
Claims for TSH testing without documented symptoms or conditions.
Mitigation Strategy
Ensure all TSH tests are linked to documented symptoms or conditions.
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 Stimulating Hormone, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Thyroid Stimulating Hormone
Use these documentation templates to ensure complete and accurate documentation for Abnormal Thyroid Stimulating Hormone. These templates include all required elements for proper coding and billing.
Subclinical Hypothyroidism
Specialty: EndocrinologyRequired Elements
- TSH level
- Free T4 level
- Symptoms
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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