ICD-9 Coding Corner: Advance Your Knowledge of Common FNA Diagnoses

Don't forget the fifth digit when reporting a toxic goiter
ICD-9 code 241.0 may be a very common diagnosis for FNA patients, but you risk mislabeling a patient - which could constitute fraudulent billing - if you assume that code before examining the physician's documentation.
 
Most fine needle aspiration (FNA) patients have 241.0 (Nontoxic uninodular goiter), 241.1 (Nontoxic multi-nodular goiter) or a diagnosis from the 242 series (Thyrotoxicosis with or without goiter), says Sherri L. Gerety, CPC, financial systems supervisor at the Wichita Clinic in Wichita, Kan. Almost all FNA patients will have a diagnosis involving a nodule, a goiter or both - the key to nailing the right code is understanding the subtle differences between the various codes in the 240, 241, 242 and 246 series.
Nodule or Goiter: Not One and the Same
"A goiter, by definition, is an enlargement of the thyroid," says Anthony Azzi, MD, clinical endocrinologist with Raleigh Endocrine Associates in Raleigh, N.C. But if the physician simply documents a goiter, she hasn't indicated if it's uninodular, multinodular, non-nodular, toxic or nontoxic, he says.
 
Use these tips to identify the most appropriate diagnosis code for a patient with a goiter:
 
1. Determine toxic or nontoxic. If a goiter is toxic, it is causing hyperthyroidism in the patient, Azzi says. Nontoxic means the patient has an enlarged thyroid (goiter) but is not hyperthyroid, he adds. For a nontoxic goiter, you'll choose from 240 and 241 series codes. For toxic goiters select a code from the 242 series.
 
2. Identify uninodular or multinodular. Both toxic and nontoxic goiters can be either uninodular or multi-nodular - and if your physician doesn't specify, you should report the unspecified code: 241.9 (Unspecified nontoxic nodular goiter) or 242.3x (Toxic nodular goiter, unspecified).
 
3. Append a fifth digit for toxic goiters. If you are reporting a toxic goiter, the ICD-9 manual instructs you to select a fifth digit to indicate whether the patient has thyrotoxic crisis or storm in addition to the goiter. Thyrotoxic storm is a rare condition and constitutes a medical emergency, Azzi says. Essentially, the condition is an extreme case of hyperthyroidism that can cause fever, extremely rapid heart beat, heart failure and much more, he says.
 
If you are performing an FNA on a patient in your office, the patient isn't likely to have thyrotoxic storm. Therefore, you should append a fifth digit of "0" to indicate "without mention of thyrotoxic crisis or storm." For example, for a patient with a toxic uninodular goiter without thyrotoxic storm, you would report 242.10.
 
4. Report 242.0 for Grave's disease. 242.0x (Toxic diffuse goiter) indicates that the patient's goiter is not a nodular goiter - it's an enlarged, overactive thyroid gland, but it contains [...]

- Published on 2004-11-21