Question: If the endocrinologist documents that the patient has hypothyroidism and doesn't include any specifics on the condition, is it correct to just report code 244 (Acquired hypothyroidism)? What if the patient has had both thyroid surgery and radiation therapy - should I report 244.0, 244.1 or both?
Georgia Subscriber
Answer: A fourth digit is definitely required when coding for hypothyroidism. That means that you should use 244.9 (Unspecified hypothyroidism) when the endocrinologist does not include the specifics of the condition in the patient's record.
If the patient has had both thyroid surgery and radiation therapy, and those are causing the hypothyroidism, you should choose the fourth digit based on the most recent factor influencing the hypothyroidism. If the patient most recently had surgery, report 244.0 (Postsurgical hypothyroidism). If the radiation therapy was more recent, report 244.1 (Other postablative hypothyroidism).
