ICD-10 Coding for Bilateral Thyroid Nodules(E04.2, E05.20)
Complete ICD-10-CM coding and documentation guide for Bilateral Thyroid Nodules. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Thyroid Nodules
E04.0-E04.9Primary Range
Other nontoxic goiter
This range includes codes for various types of nontoxic goiters, including multinodular goiter which is relevant for bilateral thyroid nodules.
Thyrotoxicosis [hyperthyroidism]
This range includes codes for toxic goiters, which may apply if the bilateral thyroid nodules are associated with hyperthyroidism.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E04.2 | Nontoxic multinodular goiter | Use when there are multiple thyroid nodules in both lobes and thyroid function tests are normal. |
|
| E05.20 | Toxic multinodular goiter without crisis | Use when there are multiple thyroid nodules with evidence of hyperthyroidism. |
|
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 bilateral thyroid nodules
Essential facts and insights about Bilateral Thyroid Nodules
Primary ICD-10-CM Codes for bilateral thyroid nodules
Decision Criteria
clinical Criteria
- Presence of multiple nodules in both thyroid lobes with normal TSH levels.
Applicable To
- Bilateral thyroid nodules with normal thyroid function
Excludes
- Toxic multinodular goiter (E05.20)
Clinical Validation Requirements
- Normal TSH levels
- Ultrasound showing multiple nodules in both thyroid lobes
Code-Specific Risks
- Misclassification as a single nodule (E04.1)
Coding Notes
- Ensure documentation specifies 'multinodular' and confirms normal thyroid function.
E05.20 - Toxic multinodular goiter without crisis
Use when there are multiple thyroid nodules with evidence of hyperthyroidism.
Applicable To
- Bilateral thyroid nodules with hyperthyroidism
Excludes
- Nontoxic multinodular goiter (E04.2)
Clinical Validation Requirements
- Suppressed TSH levels
- Elevated free T4 levels
- Ultrasound showing multiple nodules
Coding Notes
Ensure documentation includes evidence of hyperthyroidism.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Thyroid Nodules to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E04.2.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always document whether nodules are unilateral or bilateral., Use standardized templates for thyroid assessments.
Impact
Reimbursement: Incorrect code may lead to denied claims or incorrect DRG assignment., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Confirm 'multinodular' or 'bilateral' in documentation and use E04.2.
Impact
Inadequate documentation of thyroid function tests can lead to audit issues.
Mitigation Strategy
Ensure all thyroid function tests are documented and reviewed.
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 Bilateral Thyroid Nodules, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Thyroid Nodules
Use these documentation templates to ensure complete and accurate documentation for Bilateral Thyroid Nodules. These templates include all required elements for proper coding and billing.
Bilateral thyroid nodules with normal thyroid function
Specialty: EndocrinologyRequired Elements
- Nodule size in three dimensions
- Nodule composition and echogenicity
- Thyroid function test results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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