Thyromegaly: Causes, ICD-10 Coding, and Smarter Thyroid Documentation

Updated on: July 30, 2025

Thyromegaly, or enlargement of the thyroid gland, is a common clinical finding that often presents subtly but may point to significant underlying endocrine disorders. Whether caused by iodine deficiency, autoimmune conditions, or thyroid nodules, accurate evaluation and documentation of thyromegaly are essential for ensuring proper diagnosis, follow-up, and treatment.

In this guide, we’ll explore:

• What thyromegaly is and how it presents

• Clinical causes and red flags

• Proper ICD-10 coding, including E04.9

• Documentation best practices for thyroid exams

• How DocScrib simplifies endocrine documentation for busy providers

What Is Thyromegaly?

Thyromegaly refers to an enlarged thyroid gland, regardless of whether thyroid hormone levels are normal (euthyroid), elevated (hyperthyroid), or low (hypothyroid). The term is often used interchangeably with goiter, although “goiter” may refer to more specific pathologies or patterns of enlargement.

📍 Key difference:

• Thyromegaly = descriptive clinical term for thyroid enlargement

• Goiter = pathological diagnosis often documented and coded more specifically

Common Causes of Thyromegaly

Clinical Presentation

Patients may present with:

• Noticeable neck swelling

• Difficulty swallowing or breathing (in large goiters)

• Visible asymmetry in neck profile

• Hoarseness or voice changes

• Symptoms of hypothyroidism or hyperthyroidism

• No symptoms (incidental finding on exam or imaging)

ICD-10 Coding for Thyromegaly and Related Conditions

Primary ICD-10 Code

Other Relevant ICD-10 Codes

✅ Use E04.9 when the thyroid is enlarged and no specific etiology has been confirmed.

Sample SOAP Note for Thyromegaly

Subjective:
“Patient reports mild neck fullness for the past 3 months. No difficulty breathing or swallowing. No palpitations, fatigue, or weight changes.”

Objective:
Palpable, symmetrically enlarged thyroid gland without discrete nodules. No bruit or tenderness. TSH pending.

Assessment:
Thyromegaly, likely nontoxic. No compressive symptoms.
ICD-10: E04.9

Plan:

• Order thyroid panel (TSH, free T4, T3)

• Schedule thyroid ultrasound

• Monitor for signs of functional abnormality or nodular disease

• Reevaluate in 2 weeks

Diagnostic Workup for Thyromegaly

• TSH, Free T4, T3 — to determine function

• Thyroid antibodies — if autoimmune etiology suspected

• Neck ultrasound — assess size, nodules, vascularity

• Radionuclide scan (RAIU) — assess functional status

• Fine-needle aspiration (FNA) — for suspicious nodules

When to Refer or Escalate

🔶 Refer to Endocrinology if:

• Rapid thyroid growth

• Suspicion of thyroid cancer (irregular, hard, fixed mass)

• Significant symptoms (e.g., dysphagia, dyspnea, hoarseness)

• Hyperthyroid or hypothyroid labs

🔴 Urgent referral if:

• Tracheal deviation or compression

• Vocal cord paralysis

• Suspected malignancy based on imaging or FNA

Common Documentation Pitfalls

🚫 Using only “neck swelling” without specifying thyroid involvement
🚫 Omitting laterality or size of enlargement
🚫 Failing to document associated symptoms or thyroid function status
🚫 Not updating the ICD-10 code after diagnostic confirmation (e.g., from E04.9 → E04.1)

How DocScrib Helps You Document Thyromegaly Better

Thyroid-related complaints and findings can get lost in incomplete or vague documentation—especially in primary care and endocrinology settings. DocScrib uses AI to convert your voice or written notes into structured, ICD-10-ready SOAP notes.

With DocScrib, You Can:

✅ Autogenerate notes that reflect thyroid size, location, and findings
✅ Auto-suggest accurate codes like E04.9, E06.3, or E04.2 based on dictation
✅ Record physical exam findings like “diffusely enlarged, non-tender thyroid”
✅ Save time during wellness visits or endocrine evaluations
✅ Maintain consistent documentation for longitudinal thyroid monitoring

Experience smarter documentation for thyroid and endocrine care.
👉 Book your free DocScrib demo here

Quick ICD-10 Reference: Thyromegaly and Related Diagnoses

FAQs

Q1: What’s the difference between E04.9 and E04.2?
E04.9 is for unspecified goiter (thyromegaly) when a definitive cause isn’t known.
E04.2 should be used when multiple thyroid nodules are documented.

Q2: Is thyromegaly always symptomatic?
No. Many patients have asymptomatic thyroid enlargement, especially in early or mild cases.

Q3: Can thyromegaly reverse with treatment?
Yes. Depending on the cause (e.g., iodine supplementation, hormone therapy), the gland may shrink over time.

Q4: Can DocScrib document ultrasound findings automatically?
DocScrib can help summarize and integrate ultrasound results into clinical notes and suggest matching ICD-10 codes.

Final Thoughts

Thyromegaly may be benign or a signal of more serious endocrine pathology. Whether it’s part of a wellness exam or the result of a focused complaint, accurate documentation and coding—especially using ICD-10 E04.9 or related codes—ensure that patients receive appropriate evaluation and follow-up.

With DocScrib, documenting thyroid exams and navigating endocrine workups becomes faster, smarter, and more reliable.

👉 Try DocScrib now – Book your free demo here