Wiki General DX coding question

[smors1]

This is a general question about coding diagnoses from a report.
The physician dictated "Thyroid Disease" in the assessment however it was not the chief complaint for the visit. An additional note in Past HX notes "Thyroid problems" but hypo-/hyper- is not specified. Levothyroxine is in the meds list.

Can you infer that the pt. is hypothyroid and code it as such or would you code E07.9, Disorder of thyroid unspecified?

Thank you for your assistance.

 

[Riehen]

response

i would ask the MD for more specific information since the generic codes are less and less being accepted by insurance carriers and for future referencing as well.