Coding case study: hypothyroidism and radiculopathy

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.

Physical Exam

• General Appearance: normal, NAD, delightful; BP 140/90
• Peripheral Circulation: no cyanosis, clubbing, edema. No varicosities or spider veins
• Auscultation: S1& S2 within normal limits, regular rate and rhythm.
• Palpation: no thrill or palpable murmurs, no displacement of PMI
• Carotid arteries: pulses 2+, symmetric, no bruits
• Abdominal aorta: no enlargement or bruits; difficult to assess because of obesity
• Pedal pulse: Right dorsalis pedal pulse present  2+; Left dorsalis pedal pulse present  2+

Musculoskeletal

• Gait and Station: normal, able to ascend and descend table without assistance.

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.

• Psychiatric: loses interest in normal daily activities, feels hopeless at times, lacks productivity at work. Has not tried therapy.

Assessment and plan

• Chronic cervical radiculopathy: Will order x-ray of cervical region; she can try her linaments and also the patches like salon pas and aspercreme that contain lidocaine 4% - apply 12 hours on and 12 hours off
• Congenital hypothyroidism: TSH; will contact patient with results
• Major depressive disorder, recurrent: Continue Lexapro; ambulatory referral to psych for therapy; we will monitor progress at next visit
• High blood pressure: Blood pressures should be less than 130/80; document regular BP checks at home and bring with you at next visit

Documentation coding requirements

When documenting hypothyroidism, include the following:

1. Type Congenital

• Postinfectious
• Due to medicamens and other exogenous substances
• Atrophy of thyroid
• Myxedema coma

2. With or without diffuse goiter

Radiculopathy requires choosing a code based on region:

• Occipito-atlanto-axial
• Cervical
• Cervicothoracic
• Thoracic
• Thoracolumbar
• Lumbar
• Lumbosacral
• Sacral and sacrococcygeal
• Unspecified site

ICD-10 codes

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

Diagnosis codes

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 [email protected].