ICD-10 Coding for Elevated Thyroid Stimulating Hormone(R94.6, E03.9, E06.3)
Complete ICD-10-CM coding and documentation guide for Elevated 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 Elevated Thyroid Stimulating Hormone
R94.6Primary Range
Abnormal results of thyroid function studies
Used for abnormal TSH results without a confirmed diagnosis of hypothyroidism.
Hypothyroidism, unspecified
Used when hypothyroidism is confirmed with elevated TSH and low T4 levels.
Autoimmune thyroiditis
Used when elevated TSH is due to autoimmune thyroiditis, confirmed by TPO antibodies.
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 elevated but hypothyroidism is not confirmed. |
|
| E03.9 | Hypothyroidism, unspecified | Use when hypothyroidism is confirmed by labs and symptoms. |
|
| E06.3 | Autoimmune thyroiditis | Use when elevated TSH is due to autoimmune thyroiditis. |
|
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 elevated TSH
Essential facts and insights about Elevated Thyroid Stimulating Hormone
Primary ICD-10-CM Codes for elevated thyroid stimulating hormone
Decision Criteria
clinical Criteria
- TSH >4.5 mIU/mL with normal T4 and no symptoms
coding Criteria
- No confirmed diagnosis of hypothyroidism
Applicable To
- Elevated TSH without confirmed diagnosis
Excludes
- Hypothyroidism (E03.9)
Clinical Validation Requirements
- TSH >4.5 mIU/mL with normal T4
- Repeat abnormal TSH tests
Code-Specific Risks
- Using R94.6 when a definitive diagnosis exists
Coding Notes
- Ensure no definitive diagnosis of hypothyroidism before using R94.6.
E03.9 - Hypothyroidism, unspecified
Use when hypothyroidism is confirmed by labs and symptoms.
Applicable To
- Confirmed hypothyroidism with elevated TSH and low T4
Excludes
- Autoimmune thyroiditis (E06.3)
Clinical Validation Requirements
- TSH >4.5 mIU/mL with low T4
- Presence of symptoms like fatigue, weight gain
Coding Notes
Ensure low T4 and symptoms are documented.
E06.3 - Autoimmune thyroiditis
Use when elevated TSH is due to autoimmune thyroiditis.
Applicable To
- Hashimoto's thyroiditis
Clinical Validation Requirements
- Elevated TSH with positive TPO antibodies
Coding Notes
Confirm autoimmune etiology with lab tests.
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 Elevated 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 misdiagnosis of hypothyroidism., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Always document symptoms or lack thereof., Ensure lab results are included in the patient's chart.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use E03.9 or E06.3 if hypothyroidism or autoimmune thyroiditis is confirmed.
Impact
Using R94.6 when a definitive diagnosis is present.
Mitigation Strategy
Regular training on code selection and documentation.
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 Elevated Thyroid Stimulating Hormone, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Elevated Thyroid Stimulating Hormone
Use these documentation templates to ensure complete and accurate documentation for Elevated Thyroid Stimulating Hormone. These templates include all required elements for proper coding and billing.
Subclinical Hypothyroidism
Specialty: EndocrinologyRequired Elements
- TSH levels
- T4 levels
- Symptoms
- Family history
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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