# 60220-rt & 60500-59? Tia



## MELJNBBRB (Mar 5, 2015)

Hi list,
I have never used these 2 codes together, first time seeing this. Do you agree /disagree.

Thanks,
MB,CCS,CPC


PREOPERATIVE DIAGNOSIS:
Right thyroid follicular neoplasm
Right parathyroid adenoma


POSTOPERATIVE DIAGNOSIS:
Right thyroid follicular neoplasm
Right parathyroid adenoma


PROCEDURES PERFORMED:
Total thyroid lobectomy (right) with intraoperative nerve monitoring.
Bilateral central neck exploration for parathyroid adenoma.


ANESTHESIA:
General endotracheal supplemented with 0.5% Naropin local.


IV FLUIDS:
2000 mL crystalloid.


ESTIMATED BLOOD LOSS:
Minimal.


SPECIMENS:
Right thyroid lobe.  Right superior parathyroid (within the right thyroid lobe), left superior parathyroid


COMPLICATIONS:
None immediately apparent.


DVT PROPHYLAXIS:
SCDs in place and functioning prior to induction of general anesthesia.


OPERATIVE FINDINGS:
The Right recurrent laryngeal nerve was anatomically and functionally intact at the conclusion of the case by intraoperative nerve monitoring. Intraoperative frozen section revealed a large intra-thyroid parathyroid adenoma. There was no suspicious adenopathy in the central neck compartment. Intraoperative frozen section also confirmed left superior parathyroid tissue.


Intraoperative PTH measurements were as follows:
Pre-skin excision:            1139.7
Immediate post-excision:   487
10 minute post-excision:    282.5
30 minute post-excision:    194.1
60 minute post-excision:    140
100 minute post-excision:  111




INDICATIONS FOR PROCEDURE:
 is a 65 y.o.-year-old male who was found to have primary hyperparathyroidism with concerning DEXA findings.  He was also found to have a right thyroid nodule.  This nodule was targeted for FNA biopsy and was found to be a follicular neoplasm.  Pre-operative Tc-99 Sestamibi localization revealed localization to the right middle/inferior thyroid area. The patient had discussion regarding right total thyroid lobectomy with resection of parathyroid adenoma in the clinic. The risks, benefits, expectations and alternatives to these procedures were discussed in detail with Mr.   He understood that a 4-gland parathyroid exploration would be performed if the PTH value did not reach the normal range.  He had ample opportunity to ask questions and all questions were answered to his satisfaction. He gave informed consent to proceed.


PROCEDURE IN DETAIL:
The patient was identified in the preoperative holding area and taken to the operating room after injection of Tc-99 to facilitate intraoperative radio-localization of the parathyroid adenoma. He was placed on the operating table in the supine position with the arms tucked. SCDs were in place and functioning. A time-out procedure was performed and general endotracheal anesthesia was induced. Preoperative antibiotics were given. A shoulder roll was placed and the neck was extended in a neutral anatomic plane. The neck was then prepped and draped in a sterile fashion. A 4 cm incision was planned in a collar fashion, 2 fingerbreadths superior to the sternal notch in a natural skin fold. Once the incision was planned, a 0.5% Naropin local anesthetic containing epinephrine was infiltrated into the skin and subcutaneous tissues. A #15 blade scalpel was used to make the skin incision. This incision was deepened with electrocautery down through the platysma. Next, subplatysmal flaps were raised in all directions. Self-retaining retractors were inserted. The strap muscles were separated in the midline and then elevated off of the right and left thyroid lobes to the carotid arteries, bilaterally. Next, the thyroid isthmus was identified directly overlying the trachea. The isthmus was divided directly in the midline using the LigaSure device. 


Attention was then turned to the dissection of the superior pole of the Right thyroid. The cricothyroid space was bluntly developed with the Kitner. Using the LigaSure, the superior pole vessels were taken directly on the thyroid capsule. The middle thyroid vessels were then identified and taken with the LigaSure directly on the thyroid capsule.The inferior pole vessels were divided using the LigaSure directly on the thyroid capsule. Next, the gland was rotated medially and careful blunt dissection was used to identify the recurrent laryngeal nerve. Using the intraoperative nerve monitoring device as a guide, thyroid tissue directly overlying the nerve was carefully dissected away. Tissues overlying the nerve were divided using careful bipolar cautery or Hemoclips. Once sufficient tissue was divided to allow the nerve to fall into a natural position away from the thyroid, the thyroid was then elevated off of the trachea using the LigaSure.  The ex-vivo count of the easily palpable intra-thyroid nodule in the right lobe was 1500.  The remainder of the central neck had background counts of 500-600.  At this point, the specimen was passed off the field. Intraoperative pathologic evaluation of the right thyroid lobe demonstrated a large intra-thyroid parathyroid adenoma.  


Intraoperative PTH monitoring was performed and the values are given above.  The PTH fell precipitously to 1/10th the pre-operative value, however, the normal range was not achieved.  For this reason, the neoprobe was used to guide a brief exploration of the left neck.  Using careful blunt dissection guided by the neoprobe, the left superior parathyroid was identified. This in-vivo count was approximately 680, compared with background counts of 500.  This parathyroid gland was excised and confirmed to be parathyroid.  There were no other enlarged parathyroid glands in the central neck or elevated counts above the baseline.  The final PTH measurement, taken 5 minutes after excision of the left superior parathyroid gland was 111.  This was more than 1/10th the pre-operative level.  Given the lack of elevation of radioactive counts above background in any region of the central neck, coupled with the continuing decline in PTH, the decision was made to end the exploration. 


The resection bed was copiously irrigated with normal saline. The Right recurrent laryngeal nerve(s) was tested and noted to be anatomically and functionally intact. Next, the wound was instilled with normal saline. A Valsalva maneuver was performed with the assistance of the anesthesia service to 40 mmHg. There was no evidence of ongoing bleeding or bubbling. Next, 5 mL of Evicel was instilled into the surgical resection bed to assist with postoperative hemostasis. Once hemostasis was verified, the strap muscles were reapproximated in the midline using interrupted figure-of-eight silk sutures. The platysma was reapproximated using several interrupted 3-0 Vicryl sutures. The skin was approximated using running 4-0 subcuticular Monocryl suture.  Dermabond was applied as a dressing. The patient was awakened from general anesthesia and extubated on the operating room table. He tolerated the procedure well without any immediate complications and was transferred to recovery room in good condition.


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## cynthiabrown (Mar 6, 2015)

disagree   60220-Rt  and 60500. per encoder pro no mod needed


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## CULINTZ (Mar 16, 2019)

Should modifier RT or LT be used with 60220? The bilateral indicator for this CPT is "0".

I'm specifically interested in whether the modifier should be used when this is the only procedure performed to denote the side.

Thanks.


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## HBtex3 (Apr 6, 2019)

*Ccs-p, cgsc*

Yes..it is good to use the Rt/Lt modifiers on the 60220 because if they have to go back in soon after and do the other side..it clarifies and paints a picture for the payer to better understand what is going on...


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