Nontoxic single thyroid nodule
ICD-10 E04.1 is a billable code used to indicate a diagnosis of nontoxic single thyroid nodule.
A nontoxic single thyroid nodule is a localized growth within the thyroid gland that does not produce excess thyroid hormones and is not associated with hyperthyroidism. These nodules are often discovered incidentally during imaging studies or physical examinations. The majority of thyroid nodules are benign, with a small percentage being malignant. Risk factors for thyroid nodules include iodine deficiency, family history of thyroid disease, and exposure to radiation. Patients may present with a palpable mass in the neck, but many remain asymptomatic. Diagnosis typically involves a combination of clinical evaluation, thyroid function tests (TFTs), and imaging studies such as ultrasound. TFTs help assess thyroid hormone levels, which can indicate whether the nodule is functioning or not. In cases where malignancy is suspected, fine-needle aspiration biopsy may be performed to obtain tissue samples for histological examination. Management of nontoxic single thyroid nodules may include observation, regular monitoring, or surgical intervention if there are concerns regarding malignancy.
Detailed clinical notes on nodule size, characteristics, and any imaging results.
Patients presenting with a palpable thyroid nodule during routine exams or referrals for abnormal TFTs.
Endocrinologists must ensure that all relevant lab results and imaging studies are included in the patient's record.
Operative reports detailing the surgical approach and findings during thyroidectomy if performed.
Patients requiring surgical intervention due to suspicion of malignancy or symptomatic nodules.
Surgeons should document the rationale for surgery and any preoperative evaluations conducted.
Used to assess thyroid hormone levels in patients with thyroid nodules.
Results of TSH, T3, and T4 tests must be documented.
Endocrinologists should ensure that all relevant lab results are included in the patient's record.
Performed when there is suspicion of malignancy in a thyroid nodule.
Biopsy results and indications for the procedure must be documented.
Surgeons should document the rationale for the biopsy and any preoperative evaluations conducted.
A nontoxic thyroid nodule is significant as it indicates a localized growth that is not producing excess hormones, but it still requires monitoring to rule out malignancy and assess for any changes in size or symptoms.
