ICD-10 Coding for Abnormal Thyroid Function Tests(R94.6, E03.9)
Complete ICD-10-CM coding and documentation guide for Abnormal Thyroid Function Tests. 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 Tests
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 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: When to use R94.6 for thyroid tests
Essential facts and insights about Abnormal Thyroid Function Tests
Primary ICD-10-CM Codes for abnormal thyroid test
Decision Criteria
clinical Criteria
- Abnormal thyroid function tests without a specific diagnosis
coding Criteria
- Specific thyroid disorder confirmed
Applicable To
- Abnormal TSH
- Abnormal T3/T4 levels
Excludes
- Specific thyroid disorders (E03-E07)
Clinical Validation Requirements
- Elevated TSH without symptoms
- Abnormal T3/T4 without definitive diagnosis
Code-Specific Risks
- Using as primary diagnosis when a specific disorder is confirmed
Coding Notes
- R94.6 should not be used as a primary diagnosis if a specific thyroid disorder is confirmed.
E03.9 - Hypothyroidism, unspecified
Use when hypothyroidism is confirmed by symptoms and lab results.
Applicable To
- Primary hypothyroidism
Excludes
- Congenital hypothyroidism (E03.0)
Clinical Validation Requirements
- TSH >10 mU/L
- Low FT4
- Symptoms of hypothyroidism
Coding Notes
Ensure symptoms and lab results confirm hypothyroidism 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 Tests 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 audit issues., Financial: Incorrect coding may affect reimbursement.
Mitigation Strategy
Ensure all symptoms are documented, Link symptoms to lab results
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use the specific thyroid disorder code (e.g., E03.9 for hypothyroidism).
Impact
Using R94.6 as primary when a specific disorder is diagnosed.
Mitigation Strategy
Ensure specific thyroid disorder codes are used when applicable.
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 Tests, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Thyroid Function Tests
Use these documentation templates to ensure complete and accurate documentation for Abnormal Thyroid Function Tests. These templates include all required elements for proper coding and billing.
Primary Care Evaluation
Specialty: EndocrinologyRequired Elements
- Patient symptoms
- Lab results
- Clinical impression
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Abnormal Thyroid Function Tests? Ask your questions below.