ICD-10 Coding for Tetrahydrocortisol Use(E27.40, R94.6)
Complete ICD-10-CM coding and documentation guide for Tetrahydrocortisol Use. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Tetrahydrocortisol Use
E27-E29Primary Range
Disorders of adrenal glands
This range includes primary adrenal disorders that may necessitate tetrahydrocortisol testing.
Abnormal results of function studies
This range includes codes for abnormal cortisol levels, which may be identified through tetrahydrocortisol testing.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| E27.40 | Adrenocortical insufficiency, unspecified | Use when adrenal insufficiency is suspected based on clinical symptoms and lab findings. |
|
| R94.6 | Abnormal cortisol levels | Use when lab results indicate abnormal cortisol levels without a confirmed adrenal disorder. |
|
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 tetrahydrocortisol use
Essential facts and insights about Tetrahydrocortisol Use
Primary ICD-10-CM Codes for tetrahydrocortisol use
Decision Criteria
clinical Criteria
- Presence of symptoms like fatigue, hypotension, and electrolyte imbalance.
documentation Criteria
- Documented abnormal urinary THF/5α-THF ratio.
Applicable To
- Primary adrenal insufficiency
Excludes
- Congenital adrenal hyperplasia (E25.0)
Clinical Validation Requirements
- Urinary 5α-THF/THF ratio >1.5
- Elevated serum ACTH levels
Code-Specific Risks
- Misclassification if not supported by lab results
Coding Notes
- Ensure documentation includes specific metabolite ratios and test methods.
R94.6 - Abnormal cortisol levels
Use when lab results indicate abnormal cortisol levels without a confirmed adrenal disorder.
Applicable To
- Abnormal cortisol test results
Excludes
- Adrenocortical insufficiency (E27.40)
Clinical Validation Requirements
- Documented abnormal cortisol metabolite levels
Coding Notes
Ensure linkage to specific clinical findings and lab results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
THF/5α-THF ratio
LOINC 82908-5Pregnanediol/THE+THF+5α-THF ratio
LOINC 82894-7Differential 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 Tetrahydrocortisol Use to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code E27.40.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific lab values and ratios., Ensure documentation includes test methods.
Impact
Reimbursement: May lead to claim denials due to lack of specificity., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Add E27.40 and LOINC 82908-5 when ratios confirm adrenal dysfunction.
Impact
Risk of audits due to non-specific coding of adrenal disorders.
Mitigation Strategy
Ensure documentation supports specific adrenal disorder codes.
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 Tetrahydrocortisol Use, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Tetrahydrocortisol Use
Use these documentation templates to ensure complete and accurate documentation for Tetrahydrocortisol Use. These templates include all required elements for proper coding and billing.
Adrenal Insufficiency Diagnosis
Specialty: EndocrinologyRequired Elements
- Clinical symptoms
- Lab results with specific ratios
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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