ICD-10 Code E03.5 | Myxedema coma Symptoms, Diagnosis, Billing

Myxedema coma is a severe, life-threatening condition resulting from untreated hypothyroidism, characterized by a significant decrease in thyroid hormone levels. It is clinically important due to its high mortality rate if not promptly recognized and treated. The ICD-10 Code E03.5 facilitates accurate diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this critical condition.

What is ICD-10 Code E03.5 for Myxedema coma?

ICD-10 Code E03.5 represents Myxedema coma, a critical complication of hypothyroidism. This condition arises when there is a severe deficiency of thyroid hormones, leading to a state of metabolic crisis. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of Myxedema coma, ensuring proper treatment and reimbursement for the healthcare services provided.

ICD-10 Code E03.5 – Clinical Definition and Explanation of Myxedema coma

Myxedema coma is primarily caused by prolonged, untreated hypothyroidism, often precipitated by factors such as infection, cold exposure, or medication noncompliance. The condition progresses rapidly, leading to altered mental status, hypothermia, and multi-organ failure, necessitating immediate medical intervention.

Key Clinical Features:

• Severe lethargy or altered mental status
• Hypothermia (body temperature < 95°F or 35°C)
• Bradycardia (slow heart rate)
• Hypoventilation or respiratory failure
• Fluid retention and edema

ICD-10 Code E03.5 for Myxedema coma – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code E03.5 is utilized to document the diagnosis of Myxedema coma, capturing the patient's symptoms, assessment findings, and treatment plan. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition and facilitating appropriate management.

What Does ICD-10 Code E03.5 for Myxedema coma Mean in SOAP Notes?

ICD-10 Code E03.5 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Myxedema coma. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code E03.5 – Myxedema coma

Myxedema coma requires urgent hospitalization and aggressive treatment to restore thyroid hormone levels and stabilize the patient.

Antibiotic Therapy:

• Not applicable as Myxedema coma is not infectious; however, if infection is suspected, broad-spectrum antibiotics may be initiated.

Supportive Care:

• Intravenous levothyroxine administration to restore thyroid hormone levels.
• Supportive measures including warming blankets for hypothermia.
• Monitoring of vital signs and electrolyte levels.

Infection Control:

• Standard precautions should be followed to prevent healthcare-associated infections.

How to Document Symptoms of Myxedema coma (ICD-10 E03.5) in SOAP Notes

Subjective:

• Patient reports extreme fatigue and confusion.
• History of untreated hypothyroidism.
• Complaints of feeling cold and having dry skin.
• Family notes decreased responsiveness over the past few days.

Objective:

• Temperature: 93°F (34°C), indicating hypothermia.
• Heart rate: 45 beats per minute, bradycardic.
• Respiratory rate: 8 breaths per minute, hypoventilation.
• Physical exam reveals significant edema and dry skin.

Secure, compliant, and built for trust

HIPAA-compliant and designed with privacy in mind, your patient’s data is protected. Focus on care while we safeguard your information.

Learn more

SOAP Note Guidelines for Diagnosing Myxedema coma (ICD-10 Code E03.5)

Assessment:

• Diagnosis: Myxedema coma, severe (ICD-10 Code E03.5).
• Severity: Critical due to altered mental status and hypothermia.
• Contributing factors: Noncompliance with thyroid medication, recent infection.

Plan:

• Initiate IV levothyroxine therapy immediately.
• Provide supportive care including warming measures.
• Monitor vital signs and laboratory values closely.
• Consult endocrinology for further management and follow-up.

Treatment & Plan Section for ICD-10 Code E03.5 – Myxedema coma

• Administer intravenous levothyroxine as per protocol.
• Implement supportive care measures to stabilize the patient.
• Monitor for complications such as respiratory failure.
• Schedule follow-up with endocrinology for ongoing management.

Using ICD-10 Code E03.5 for Myxedema coma in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
• Use the code E03.5 when the patient presents with severe hypothyroidism symptoms.
• Align treatment plans with clinical guidelines to support justified billing.
• Include relevant CPT codes for services rendered alongside the diagnosis.

Related ICD-10 Codes Often Used with Myxedema coma

• E03.9 – Hypothyroidism, unspecified
• E03.8 – Other specified hypothyroidism
• E03.0 – Congenital hypothyroidism
• E03.1 – Myxedema

ICD-10 Code E03.5 in Medical Billing and Insurance for Myxedema coma

ICD-10 Code E03.5 is crucial for billing in hospital, emergency room, or infectious disease care settings.

Billing Notes:

• Document all relevant clinical findings and treatment interventions to support the claim.
• Use E03.5 in conjunction with other codes for comprehensive billing.
• Ensure that the diagnosis is clearly linked to the services provided.

Common CPT Pairings: