Check out the following scenario and see if you can choose the correct codes.
New patient presents for follow up of radiculopathy, hypothyroidism. She’s had pain in her neck, upper back and shoulders for 10 years. She has long history of depression.
Shoulders are without overt deformity; no erythema, warmth or edema. There is pain with movement; ROM of the shoulders without crepitus or popping.
She has neck pain and then also numbness (dormido) in the left hand 4th and 5th digits. Mostly positional.
Muscle strength normal; reflexes somewhat diminished in upper extremities; no sensation loss.
Assessment and plan
Documentation coding requirements
When documenting hypothyroidism, include the following:
1. Type Congenital
2. With or without diffuse goiter
Radiculopathy requires choosing a code based on region:
Hypothyroidism ICD-10 codes
E03.0 Congenital hypothyroidism with diffuse goiter
E03.1 Without goiter
E03.2 Hypothyroidism due to medicaments and other exogenous substances*
E03.3 Postinfectious hypothyroidism
E03.4 Atrophy of thyroid (acquired)
E03.5 Myxedema coma
E03.8 Other specified hypothyroidism
E03.9 Hypothyroidism, unspecified
Radiculopathy ICD-10 codes
M54.10 Radiculopathy, site unspecified
M54.11 occipito-atlanto-axial region
M54.12 cervical region
M54.13 cervicothoracic region
M54.14 thoracic region
M54.15 thoracolumbar region
M54.16 lumbar region
M54.17 lumbosacral region
M54.18 sacral and sacrococcygeal region
M54.12 Radiculopathy, cervical region
E03.1 Congenital hypothyroidism without goiter
F33.1 Major depressive disorder, recurrent, moderate
R03.0 Elevated blood-pressure reading, without diagnosis of hypertension
Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to firstname.lastname@example.org.