ICD-10 Code E06.3 | Autoimmune thyroiditis Symptoms, Diagnosis, Billing

Autoimmune thyroiditis, also known as Hashimoto's thyroiditis, is an autoimmune disorder characterized by the immune system attacking the thyroid gland, leading to inflammation and often resulting in hypothyroidism. Accurate coding with ICD-10 Code E06.3 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and treatment.

What is ICD-10 Code E06.3 for Autoimmune thyroiditis?

ICD-10 Code E06.3 represents Autoimmune thyroiditis, a condition where the immune system mistakenly attacks the thyroid gland, causing inflammation and potential thyroid dysfunction. This code should be used in clinical documentation and billing when diagnosing patients with this autoimmune disorder, particularly when symptoms of hypothyroidism or goiter are present.

ICD-10 Code E06.3 – Clinical Definition and Explanation of Autoimmune thyroiditis

Autoimmune thyroiditis is primarily caused by an autoimmune response that leads to chronic inflammation of the thyroid gland. The condition can progress to hypothyroidism, necessitating medical intervention. Early diagnosis and treatment are crucial to prevent complications associated with thyroid dysfunction.

Key Clinical Features:

• Fatigue and weakness due to hypothyroidism
• Goiter or enlarged thyroid gland
• Weight gain and sensitivity to cold
• Depression and cognitive changes

ICD-10 Code E06.3 for Autoimmune thyroiditis – SOAP Notes & Clinical Use

ICD-10 Code E06.3 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plans. It 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 E06.3 for Autoimmune thyroiditis Mean in SOAP Notes?

In SOAP notes, ICD-10 Code E06.3 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of autoimmune thyroiditis. This code is essential for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code E06.3 – Autoimmune thyroiditis

Autoimmune thyroiditis may require hospitalization if severe symptoms arise or complications develop. Treatment focuses on managing thyroid hormone levels and alleviating symptoms.

Antibiotic Therapy:

Supportive Care:

• Levothyroxine replacement therapy to manage hypothyroidism
• Regular monitoring of thyroid function tests
• Patient education on symptom management

Infection Control:

How to Document Symptoms of Autoimmune thyroiditis (ICD-10 E06.3) in SOAP Notes

Subjective:

• Patient reports fatigue and weight gain over the past few months.
• Complaints of sensitivity to cold and dry skin.
• History of depression and cognitive difficulties.

Objective:

• Thyroid gland palpation reveals enlargement.
• Vital signs: BP 120/80, HR 70, Temp 98.6°F.
• Laboratory results show elevated TSH and low free T4.

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SOAP Note Guidelines for Diagnosing Autoimmune thyroiditis (ICD-10 Code E06.3)

Assessment:

• Diagnosis: Autoimmune thyroiditis (E06.3), moderate severity.
• ICD-10 subcode: N/A.
• Triggers: Family history of autoimmune diseases.

Plan:

• Initiate levothyroxine therapy and titrate based on TSH levels.
• Educate patient on the importance of medication adherence.
• Schedule follow-up in 6 weeks for thyroid function re-evaluation.

Treatment & Plan Section for ICD-10 Code E06.3 – Autoimmune thyroiditis

• First-line treatment includes levothyroxine for hypothyroidism.
• Encourage lifestyle modifications such as a balanced diet and regular exercise.
• Monitor thyroid function tests every 6-12 months.
• Provide education on recognizing symptoms of thyroid dysfunction.

Using ICD-10 Code E06.3 for Autoimmune thyroiditis in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
• Use E06.3 for all relevant encounters related to autoimmune thyroiditis.
• Align treatment plans with clinical guidelines to support justified billing.
• Include necessary CPT codes that correspond to the services provided.

Related ICD-10 Codes Often Used with Autoimmune thyroiditis

• E03.9 – Hypothyroidism, unspecified
• E06.1 – Subacute thyroiditis
• E05.90 – Thyroid storm, unspecified
• E04.9 – Goiter, unspecified

ICD-10 Code E06.3 in Medical Billing and Insurance for Autoimmune thyroiditis

ICD-10 Code E06.3 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and clinical findings to support the use of E06.3.
• Use this code in conjunction with appropriate CPT codes for thyroid function tests and consultations.
• Ensure compliance with payer-specific guidelines for documentation.

Common CPT Pairings: