February 14, 2011

Coding for Thyroid Diseases
For The Record
Vol. 23 No. 3 P. 27

The thyroid gland, which is located at the base of the neck, releases hormones that regulate all aspects of metabolism. The following are some common diseases that may occur if the thyroid is not functioning properly.

Hypothyroidism
Hypothyroidism occurs if the thyroid does not produce enough hormones. Common signs and symptoms of hypothyroidism include fatigue; weakness; weight gain; coarse, dry hair; dry, rough, pale skin; hair loss; intolerance to the cold; muscle cramps; constipation; depression; irritability; memory loss; abnormal menstrual cycles; and decreased libido.

The signs and symptoms may vary widely depending on the severity of hormone deficiency. If hypothyroidism goes untreated, it may lead to an enlarged thyroid (goiter). Very severe, advanced hypothyroidism, which can be life threatening, is called myxedema.

Hypothyroidism is classified to ICD-9-CM category 244. A fourth digit is required to identify the specific type of hypothyroidism as follows:

• 244.0, Postsurgical hypothyroidism;

• 244.1, Other postablative hypothyroidism, including hypothyroidism following therapy such as irradiation;

• 244.2, Iodine hypothyroidism;

• 244.3, Other iatrogenic hypothyroidism;

• 244.8, Other specified acquired hypothyroidism, including secondary hypothyroidism; and

• 244.9, Unspecified hypothyroidism.

Hypothyroidism is diagnosed primarily based on the amount of thyroid hormone measured in the blood. Hypothyroidism is treated with the synthetic thyroid hormone levothyroxine (Levothroid, Synthroid), which restores adequate hormone levels.

Hyperthyroidism
In hyperthyroidism, the thyroid gland produces too much of the thyroid hormone and accelerates the body’s metabolism. Common signs and symptoms of hyperthyroidism include heart palpitations, increased heart rate, intolerance to heat, nervousness, insomnia, breathlessness, increased bowel movements, light or absent menstrual periods, fatigue, trembling hands, weight loss, muscle weakness, hair loss, and warm, moist skin.

Hyperthyroidism is classified to category 242, with a fourth digit required to identify the specific type of disease such as the following:

• 242.0, Toxic diffuse goiter, including Basedow’s disease, Exophthamic or toxic goiter, Graves’ disease, and primary thyroid hyperplasia;

• 242.1, Toxic uninodular goiter;

• 242.2, Toxic multinodular goiter;

• 242.3, Toxic nodular goiter, unspecified;

• 242.4, Thyrotoxicosis from ectopic thyroid nodule;

• 242.8, Thyrotoxicosis of other specified origin; and

• 242.9, Thyrotoxicosis without mention of goiter or other cause.

In addition, a fifth-digit subclassification is required with category 242 as follows:

• 0 — without mention of thyrotoxic crisis or storm; and

• 1 — with mention of thyrotoxic crisis or storm.

A thyroid storm is a sudden, extreme overactivity of the thyroid gland. It may produce a fever, extreme weakness, mood swings, confusion, altered consciousness, coma, and enlarged liver with jaundice. It may be life threatening if not treated emergently.

Treatment for hyperthyroidism may include one or more of the following: radioactive iodine, antithyroid medications such as propylthiouracil and methimazole (Tapazole), beta-blockers to reduce rapid heart rate and prevent palpitations, and surgery such as thyroidectomy.

Thyroid Goiter
A nontoxic goiter is an enlargement of the thyroid that is not associated with the overproduction of thyroid hormone or malignancy. Nontoxic nodular goiter is classified to category 241. A fourth-digit subcategory is required to specify the type of goiter as follows:

• 241.0, Nontoxic uninodular goiter;

• 241.1, Nontoxic multinodular goiter; and

• 241.9, Unspecified nontoxic nodular goiter.

Category 240 identifies simple and unspecified goiter with the fourth-digit subcategory as follows:

• 240.0, Goiter, specified as simple; and

• 240.9, Goiter, unspecified.

Toxic goiters are classified to category 242 and were discussed under the hyperthyroidism section.

Graves’ Disease
Also called diffuse toxic goiter, Graves’ disease (242.0x) is the most common form of hyperthyroidism. It is an autoimmune disorder in which the immune system attacks the thyroid gland and causes it to overproduce thyroxine, a thyroid hormone. The signs and symptoms are the same as hyperthyroidism with three additional characteristic symptoms: goiter, bulging eyes (exophthalmos), and raised areas of skin over the shins.

Hashimoto’s Disease
Hashimoto’s disease (245.2) is an autoimmune disorder that causes inflammation of the thyroid gland and often leads to hypothyroidism. Also called autoimmune thyroiditis and chronic lymphocytic thyroiditis, the signs and symptoms for Hashimoto’s disease are the same as hypothyroidism.

Thyroid Nodules
Thyroid nodules are abnormal growths or lumps in the thyroid gland. The nodules may be solid or fluid filled and benign or malignant. Benign nodules are the most common and may cause no symptoms. Malignant nodules may not cause any signs or symptoms in the early stages but may cause the following as the cancer grows: a lump just below the Adam’s apple, hoarseness, difficulty swallowing or breathing, swollen lymph nodes in the neck, pain in the throat or neck, and symptoms of hyperthyroidism or hypothyroidism.

Thyroid nodules are classified to ICD-9-CM code 241.0, Nontoxic uninodular goiter. If the thyroid nodule occurs with hyperthyroidism or thyrotoxicosis, assign code 242.1x. A fifth-digit subclassification is needed to identify presence or absence of thyrotoxic crisis or storm. Benign neoplasm of the thyroid gland is classified to code 226. Malignancy of the thyroid gland is assigned to code 193.

Coding and sequencing for thyroid diseases are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

Coding for Thyroid Diseases in ICD-10-CM
In ICD-10-CM, disorders of the thyroid gland are classified to categories E00 to E07. The categories are as follows:

• E00, Congenital iodine-deficiency syndrome;

• E01, Iodine-deficiency related thyroid disorders and allied conditions;

• E02, Subclinical iodine-deficiency hypothyroidism;

• E03, Other hypothyroidism;

• E04, Other nontoxic goiter;

• E05, Thyrotoxicosis [hyperthyroidism];

• E06, Thyroiditis; and

• E07, Other disorders of thyroid.

Currently, the coding directives related to thyroid diseases are the same in ICD-10-CM as in ICD-9-CM, although some conditions are classified to different chapters or different blocks. For example, in ICD-9-CM, postsurgical hypothyroidism is classified to code 244.0, which is in the hypothyroidism category. However, in ICD-10-CM, postsurgical hypothyroidism is not located under category E03, Other hypothyroidism. Instead, it is classified to code E89.0. Category E89 is titled “Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified.”

— Audrey Howard