Pediatric Endocrinology Referral Guidelines Thank you for referring your patients to our division. We are striving to provide the best possible experience for your patients and also meet your needs as a primary care provider. To that end, we have created referral guidelines that will help you perform preliminary laboratory and radiologic evaluations prior to your patient seeing one of our subspecialists. Remember, these are just guidelines and if you are unable to perform a work up, we will still see your patient in a timely manner. Also, we are not expecting anyone to interpret the lab or radiology results, thus please call our clinic if you feel there is an urgent consult required. We have attempted to delineate specific cases where an urgent referral is indicated. While we would like all laboratories to be created equal and perform the same test in the same way, they are not. Thus, we usually prefer lab tests to be performed at CPL, LabCorp, Quest, or Esoterix. However, even amongst these facilities, they don’t always have the ideal endocrine tests available and we may send blood to special reference laboratories. We ask that you inform your patients while you are performing a preliminary work up, that there may be other labs or tests that are warranted. We generally prefer to review our own bone ages, as there is a lot of variation amongst radiologists. We have access to studies performed at ARA, ARC, Seton, CPRMC, and some Telerad facilities. If you perform a bone age outside of one of these facilities, please send the image on a CD with your patient. This will help us give a more complete, efficient work up of your patient. We have attempted to label which tests should be performed at 8am, fasting, or both. If a work up calls for these special conditions, all the labs can be performed at that time (there should not be a need for 2 separate lab draws). The referral guidelines have several sections of “Key Facts” about certain conditions. Please review these when you are making a referral, as this information may guide your work up. We have also included an algorithm for treating Vitamin D deficiency. This treatment protocol is one of many ways to treat this condition; however, it should only be followed if the patient has normal Ca, Phos, and PTH levels. If the patient has abnormal levels, multiple fractures or signs of rickets, please contact our office for a referral or more instructions. If you have any questions or concerns about these guidelines, please contact the MD on call and we will be happy discuss them with you. As always, if you feel you have an Endocrine Emergency, please call our clinic (512-628-1830) or the after-hours MD on call (Medlink 512-323-5465). We look forward to working with you as we care for the children of Central Texas. Regards, The Division of Pediatric Endocrinology ‘Specially for Children Dell Children’s Medical Center of Central Texas Pediatric Endocrinology Referral Guidelines Table of Contents: 1a) Congenital Hypothyroidism (Neonate) [ICD-9 Code: 243.0] [ICD-10 Code: E03.1] 1b) Congenital Hypothyroidism (Child) [ICD -9 Code: 243.0] [ICD-10 Code: E03.1] 2a) Acquired Hypothyroidism [ICD-9 Code: 244.8] [ICD-10 Code: E03.8] 2b) Autoimmune Thyroiditis/Hypothyroidism [ICD-9 Code: 245.2] [ICD-10 Code: E06.3] 3) Central Hypothyroidism [ICD-9 Code: 253.4] [ICD-10 Code: E23.6] 4a) Acquired Hyperthyroidism [ICD-9 Code: 242.9] [ICD-10 Code: E05.90] 4b) Autoimmune Hyperthyroidism (Grave’s Disease) [ICD-9 Code: 242.0] [ICD-10 Code: E05.00] 5) Neonatal Hyperthyroidism [ICD-9 Code: 775.3] [ICD-10 Code: P72.1] 6) Goiter [ICD-9 Code: 240.9] [ICD-10 Code: E04.9] 7) Thyroid Nodule [ICD-9 Code: 243.0] [ICD-10 Code: E04.1] Thyroid: Key Facts (page 8) 8a) Diabetes Mellitus - Type 1 [ICD-9 Code: 250.03; ICD-10: E10.65] Type 2 [ICD-9 Code: 250.02; ICD-10: E11.65] 8b) Hyperglycemia [ICD-9 Code: 790.29] [ICD-10 Code: R73.09] 9a) Impaired Glucose Tolerance [ICD-9 Code: 790.22] [ICD-10 Code: R73.02] 9b) Impaired Fasting Glucose [ICD -9 Code: 790.21] [ICD-10 Code: R73.01] 10a) Morbid Obesity [ICD-9 Code: 278.01] [ICD-10 Code: E66.01] 10b) Acanthosis Nigricans [ICD-9 Code: 701.2] [ICD-10 Code: L83] Diabetes: Key Facts (page 10) (Table of contents continued on next page) For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 1 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines Table of Contents (continued): 11) Short Stature [ICD-9 Code: 783.43] [ICD-10 Code: R62.52] 12) Failure to Thrive [ICD-9 Code: 783.41] [ICD-10 Code: R62.51] Growth: Key Facts (pages 13 & 14) 13a) Precocious Puberty/Premature Thelarche - Girls [ICD-9 Code: 259.1] [ICD-10 Code: E30.1] 13b) Precocious Puberty - Boys [ICD-9 Code: 259.1] [ICD-10 Code: E30.1] Precocious Puberty: Key Facts (page 16) 14a) Premature Adrenarche - Girls [ICD-9 Code: 255.2] [ICD-10 Code: E27.0] 14b) Premature Adrenarche - Boys [ICD-9 Code: 255.2] [ICD-10 Code: E27.0] 15) Delayed Puberty [ICD-9 Code: 259.0] [ICD-10 Code: E30.0] 16) Algorithm for Treating Vitamin D Deficiency [ICD-9 Code: 268; ICD-10 Code: E55.9] For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 2 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines 1a) Congenital Hypothyroidism (Neonate) [ICD-9 Code: 243.0] [ICD-10 Code: E03.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements • Neonate with abnormal ► URGENT: ► Confirmatory TSH, Total T4 or Free T4 ► All clinical notes and laboratory Newborn Screening Test Call MD on-call to results including growth chart discuss and start treatment. On -Call Phone # Day: (512) 628-1830 After Hours: (512) 323-5465 1b) Congenital Hypothyroidism (Child) [ICD-9 Code: 243.0] [ICD-10 Code: E03.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements • Known or treated child with ► First available ► Current TSH, Total or Free T4 ► All clinical notes and laboratory results including growth chart abnormal thyroid function appointment, but call the test MD on-call to begin therapy until patient can be seen. For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 3 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines 2a) Acquired Hypothyroidism [ICD-9 Code: 244.8] [ICD-10 Code: E03.8] 2b) Autoimmune Thyroiditis/Hypothyroidism [ICD-9 Code: 245.2] [ICD-10 Code: E06.3] Clinical Findings Referral Timeframe Pre- Referral Workup Referral Requirements • Elevated TSH ► First available ► Current TSH, Total T4 or Free T4, Anti- ► All clinical notes and laboratory Thyroglobulin Antibody and Anti-TPO records including growth chart appointment, but call the • Low Total T4 or Free T4 MD on-call to begin Antibody therapy until patient can ► If TSH is abnormal but <10 uU/ml and the be seen Total T4 or Free T4 are normal, obtain thyroid antibodies and repeat the TSH, Total T4 or Free T4 in 1-2 months. If TSH rising and antibodies are positive, refer ► Thyroid ultrasound is unnecessary unless the gland is asymmetric or nodules are palpable 3) Central Hypothyroidism [ICD-9 Code: 253.4] [ICD-10 Code: E23.6] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements • Low to Low normal TSH with ► URGENT: ► Confirmatory TSH, Total T4 ► All clinical notes and laboratory or Free T4 records including growth chart low Total T4 or Free T4 Call MD on-call to discuss and start treatment. ► Consider repeat of labs prior • History of traumatic brain to referral to assure validity injury, midline facial On-Call Phone # defects, brain irradiation, Day: hypoxic brain injury (512) 628-1830 After Hours: (512) 323-5465 ► After discussion with MD on-call, may be asked to obtain MRI of the brain and pituitary with and without contrast For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 4 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines 4a) Acquired Hyperthyroidism [ICD-9 Code: 242.9] [ICD-10 Code: E05.90] 4b) Autoimmune Hyperthyroidism (Grave’s Disease) [ICD-9 Code: 242.0] [ICD-10 Code: E05.00] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements • Hypertension ► URGENT: ► Current TSH, Total T4 or Free T4, ► All clinical notes and laboratory Total T3, Thyroid Stimulating records including growth chart Call MD on-call to • Tachycardia discuss and start Immunoglobulin (TSI), Thyrotropin Binding treatment. Immunoglobulin (TBII), Anti-Thyroglobulin Goiter • Antibody, Anti-TPO Antibody On-Call Phone # • Exophthalmos Day: • TSH < 0.1 uU/ml (512) 628-1830 • Elevated Total T4 or After Hours: Free T4,T3 (512) 323-5465 5) Neonatal Hyperthyroidism [ICD-9 Code: 775.3] [ICD-10 Code: P72.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements • Maternal history of Graves ► URGENT: ► TSH, Total T4 or Free T4, Total T3, ► All clinical notes and laboratory Disease Call MD on-call to Thyroid Stimulating Immunoglobulin (TSI), records including growth chart Thyrotropin-Binding Immunoglobulin (TBII) discuss and start • Hypertension treatment.