ICD-10 Coding for History of Hypothyroidism(Z86.39, E03.9)
Complete ICD-10-CM coding and documentation guide for History of Hypothyroidism. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Hypothyroidism
Z86-Z87Primary Range
Personal history of certain other diseases
This range includes codes for personal history of endocrine disorders, which is relevant for documenting resolved hypothyroidism.
Other hypothyroidism
This range includes codes for active hypothyroidism, which is relevant for differentiation from historical conditions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z86.39 | Personal history of other endocrine, nutritional and metabolic disease | Use when the patient has a resolved history of hypothyroidism with no current management. |
|
| E03.9 | Hypothyroidism, unspecified | Use for active hypothyroidism under management. |
|
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 history of hypothyroidism
Essential facts and insights about History of Hypothyroidism
Primary ICD-10-CM Codes for history of hypothyroidism
Decision Criteria
clinical Criteria
- No current symptoms or treatment for hypothyroidism
documentation Criteria
- Explicit mention of resolved hypothyroidism
Applicable To
- Personal history of hypothyroidism
Excludes
- Active hypothyroidism (E03.-)
Clinical Validation Requirements
- Documented resolution of hypothyroidism
- No current treatment or management required
Code-Specific Risks
- Misuse for active conditions leading to incorrect coding
Coding Notes
- Ensure documentation clearly states the condition is historical and not currently managed.
E03.9 - Hypothyroidism, unspecified
Use for active hypothyroidism under management.
Applicable To
- Active hypothyroidism without specified cause
Excludes
- Resolved hypothyroidism (Z86.39)
Clinical Validation Requirements
- TSH >4.5 mIU/L
- Ongoing treatment with levothyroxine
Coding Notes
Ensure active management is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of malignant neoplasm of thyroid
Z85.850Differential 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 History of Hypothyroidism to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z86.39.
Impact
Clinical: Misinterpretation of patient status, Regulatory: Potential audit issues, Financial: Incorrect billing
Mitigation Strategy
Use specific terms like 'resolved hypothyroidism', Ensure no active treatment is noted
Impact
Reimbursement: Incorrect reimbursement due to misclassification, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Use E03.9 or specific etiology code if actively managing the condition.
Impact
Using history codes for active conditions can lead to audits.
Mitigation Strategy
Verify patient status and treatment before coding.
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 History of Hypothyroidism, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Hypothyroidism
Use these documentation templates to ensure complete and accurate documentation for History of Hypothyroidism. These templates include all required elements for proper coding and billing.
Resolved hypothyroidism documentation
Specialty: EndocrinologyRequired Elements
- Patient history
- Resolution status
- Current thyroid function
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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