ICD-10 Coding for History of Thyroidectomy(Z90.09, Z85.850, E89.0)
Complete ICD-10-CM coding and documentation guide for History of Thyroidectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Thyroidectomy
Z85-Z99Primary Range
Persons with potential health hazards related to family and personal history and certain conditions influencing health status
This range includes codes for personal history of diseases and conditions, including history of thyroidectomy.
Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified
This range covers complications that may arise after thyroidectomy, such as hypothyroidism.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z90.09 | Acquired absence of other parts of head and neck | Use when documenting the absence of the thyroid gland post-surgery, regardless of the reason for removal. |
|
| Z85.850 | Personal history of malignant neoplasm of thyroid | Use for patients with a history of thyroid cancer post-thyroidectomy. |
|
| E89.0 | Postprocedural hypothyroidism | Use when hypothyroidism is directly linked to the thyroidectomy procedure. |
|
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 thyroidectomy
Essential facts and insights about History of Thyroidectomy
Primary ICD-10-CM Codes for history of thyroidectomy
Decision Criteria
clinical Criteria
- Absence of thyroid confirmed by imaging or surgical history
Applicable To
- Absence of thyroid
Excludes
- Congenital absence of thyroid (E03.1)
Clinical Validation Requirements
- Operative report confirming thyroidectomy
- Imaging showing absence of thyroid tissue
Code-Specific Risks
- Incorrectly used for congenital absence
Coding Notes
- Ensure documentation specifies acquired absence due to surgery.
Z85.850 - Personal history of malignant neoplasm of thyroid
Use for patients with a history of thyroid cancer post-thyroidectomy.
Applicable To
- History of thyroid cancer
Excludes
- Current malignancy of thyroid (C73)
Clinical Validation Requirements
- Pathology report confirming past malignancy
- Surgical note indicating cancer-related thyroidectomy
Coding Notes
Ensure documentation specifies the history of malignancy.
E89.0 - Postprocedural hypothyroidism
Use when hypothyroidism is directly linked to the thyroidectomy procedure.
Applicable To
- Hypothyroidism due to thyroidectomy
Excludes
- Primary hypothyroidism (E03.9)
Clinical Validation Requirements
- Elevated TSH levels post-surgery
- Documentation linking hypothyroidism to thyroidectomy
Coding Notes
Ensure linkage to surgery is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Postprocedural hypothyroidism
E89.0Differential 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 Thyroidectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.09.
Impact
Clinical: Inaccurate patient history, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Review surgical history, Confirm with pathology reports
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient history records.
Mitigation Strategy
Use Z86.010 for benign conditions such as goiter.
Impact
Using Z85.850 as primary when the visit is for hypothyroidism management.
Mitigation Strategy
Ensure the primary code reflects the reason for the encounter.
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 Thyroidectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Thyroidectomy
Use these documentation templates to ensure complete and accurate documentation for History of Thyroidectomy. These templates include all required elements for proper coding and billing.
Endocrinology Follow-Up Post-Thyroidectomy
Specialty: EndocrinologyRequired Elements
- Patient history of thyroidectomy
- Reason for surgery
- Current symptoms and lab results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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