ICD-10 Coding for Multinodular Thyroid(E04.2, E05.21)
Complete ICD-10-CM coding and documentation guide for Multinodular Thyroid. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Multinodular Thyroid
E00-E07Primary Range
Disorders of thyroid gland
This range includes all thyroid disorders, with E04.2 specifically for nontoxic multinodular goiter.
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 with normal thyroid function tests. |
|
| E05.21 | Thyrotoxicosis with toxic multinodular goiter | Use when multinodular goiter is associated with 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 multinodular thyroid
Essential facts and insights about Multinodular Thyroid
Primary ICD-10-CM Codes for multinodular thyroid
Decision Criteria
clinical Criteria
- Presence of multiple thyroid nodules with normal TSH levels.
coding Criteria
- Avoid using E04.2 if TSH is suppressed.
Applicable To
- Cystic goiter
- Colloid goiter
- Parenchymatous goiter
Clinical Validation Requirements
- Palpable nodules ≥1 cm
- Normal TSH/T4 levels
- Ultrasound confirmation of ≥2 nodules
Code-Specific Risks
- Confusion with toxic multinodular goiter if TSH is suppressed.
Coding Notes
- Ensure ultrasound confirmation of nodules to support E04.2 coding.
E05.21 - Thyrotoxicosis with toxic multinodular goiter
Use when multinodular goiter is associated with hyperthyroidism.
Excludes
- Nontoxic multinodular goiter (E04.2)
Clinical Validation Requirements
- Elevated T3/T4
- Suppressed TSH
- Symptoms of thyrotoxicosis
Coding Notes
Ensure documentation of thyrotoxic symptoms and lab results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Neck mass/swelling
R19.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Multinodular Thyroid to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E04.2.
Impact
Clinical: Lack of specificity in diagnosis., Regulatory: Potential audit issues., Financial: Reduced reimbursement rates.
Mitigation Strategy
Ensure detailed documentation of nodule characteristics., Use specific codes based on clinical findings.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Verify TSH levels to differentiate between nontoxic and toxic goiter.
Impact
Failure to document nodule details can lead to incorrect coding.
Mitigation Strategy
Implement standardized documentation templates.
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 Multinodular Thyroid, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Multinodular Thyroid
Use these documentation templates to ensure complete and accurate documentation for Multinodular Thyroid. These templates include all required elements for proper coding and billing.
Routine evaluation of multinodular goiter
Specialty: EndocrinologyRequired Elements
- Patient history
- Physical examination findings
- Laboratory results
- Imaging studies
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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