General Surgery Coding Alert
Meet the Challenge of Thyroidectomy Coding
The thyroid is the largest of the endocrine glands, consisting of two lateral lobes connected by an isthmus. A third pyramidal lobe sometimes extends from the isthmus. The gland may become malignant or enlarged (goiter), which can result in partial or total removal. When malignancy is not involved, the surgeon may attempt to preserve thyroid function by saving portions of the gland.
Thyroid excision and related codes range from simple aspiration and biopsy to total thyroidectomy (when the entire thyroid is removed). The code list includes partial lobectomies, total lobectomies (sometimes referred to as a partial thyroidectomy) and subtotal" thyroidectomies and lobectomies :-- when most but not all of the lobe or complete thyroid has been removed. If part of the thyroid was removed for reasons unrelated to malignancy with some thyroid tissue saved to preserve function the surgeon may subsequently remove the remaining tissue. This service is reported by yet another code.
The surgeon may also remove a portion or all of the parathyroid glands (tissue adjacent to the thyroid that surgeons normally try not to disturb). When removal of a specific parathyroid gland or removal of most of the parathyroid tissue is performed for specific problems with these glands different codes -- some of which are bundled with some thyroid excision codes -- apply.
Biopsies Lobectomies and Other Partial Excisions
Thyroid biopsies injections cyst excisions and partial excisions are described by seven codes:
These procedures can be difficult to tell apart says Tray Dunaway MD FACS a general surgeon in private practice in Camden S.C. "People sometimes refer to total lobectomies where an entire lobe is removed as a total thyroidectomy " he says noting that many coders may not understand subtotal thyroidectomies or lobectomies or what makes them different from partial or total procedures.
When only a part of one thyroid lobe is excised (i.e. partial lobectomy) 60210 should be used. Sometimes part of one lobe and the greater portion of the other lobe may be removed simultaneously and 60212 should be reported. A "subtotal" lobectomy involves the excision of most of the thyroid lobe. Similarly a subtotal thyroidectomy involves removal of the greater portion of the entire thyroid gland.
Report 60220 when a complete lobe is removed. If a subtotal lobectomy (including isthmusectomy which involves the excision of the narrow connection between the two lobes of the thyroid gland) is also performed use 60225.
Total Thyroidectomies
Total thyroidectomies performed by general surgeons are reported with three codes:
If a total thyroidectomy is performed without neck dissection of any kind only 60240 should be reported.
Although some surgery coders have been instructed to use 60240 only when the total thyroidectomy is performed for reasons other than cancer this is wrong says Kathleen Mueller RN CPC CCS-P CCC an independent general surgery coding reimbursement and compliance specialist in Lenzburg Ill. "Whatever the diagnosis if a total thyroidectomy is performed without an accompanying neck dissection 60240 is correct " she says. "Lymph nodes are not automatically removed just because there is a thyroid malignancy. It is up to the surgeon to decide if lymph nodes should be removed."
Most surgeons do not perform radical or modified radical neck dissections. Furthermore thyroid tumors tend to be "indolent " or slow-growing. But even when this is the case the surgeon may perform "limited" neck dissection -- which involves the removal of a few enlarged lymph nodes only -- to make sure the cancer has not spread. When this occurs 60252 which includes limited neck dissection should be reported Mueller says.
Occasionally a frozen-section report can return as carcinoma but when the gland is removed and sectioned the report may show atypia or dysplasia not an actual carcinoma. In such cases even though 60252 states "for malignancy " it is acceptable to use 237.4 (neoplasm uncertain behavior endocrine glands) as the diagnosis.
"The term 'neoplasm uncertain behavior' means that the tissue is in transition from a benign to a malignant process " Mueller says. "It does not mean that the tissue or tumor looks suspicious. It means that a pathology report has indicated the diagnosis."
Mueller notes that some practices inappropriately assign 237.4 as the diagnosis instead of waiting for the pathology report. But using 237.4 even if the surgeon finds the tissue suspicious can erroneously label the patient if the pathology report returns negative.
When thyroidectomies are performed due to goiter or any other malignancy the surgeon will likely try to preserve the gland's function by performing a partial or subtotal lobectomy or thyroidectomy 60210-60225. Later the remaining tissue may need to be removed. For example if cancer is detected in the remaining thyroid tissue or nearby lymph nodes the surgeon may have to remove the remaining tissue. This is reported with 60260.
Reporting Parathyroidectomy
Surgeons may remove tissue from both the thyroid and the parathyroids which often have variable anatomy ranging from two to six glands sometimes in variable anatomic locations Dunaway says.
Four CPT codes describe parathyroid surgery:
For partial parathyroidectomy three or three-and-a-half glands are removed leaving one gland (or at least some tissue) to prevent hypoparathyroidism. When a total parathyroidectomy (60500) involving all four glands is performed the surgeon may reimplant one gland in the forearm muscle to provide residual parathyroid function and easy access to the remaining gland after surgery. This procedure called parathyroid autotransplantation is reported using 60512 an add-on code that should never be billed on its own.
Parathyroid removal is incidental to a thyroidectomy and the two services are bundled in the national Correct Coding Initiative. If during a thyroidectomy the surgeon notes an unusual lesion on the thyroid and later performs a biopsy and/or a thyroid excision the appropriate thyroidectomy code may be billed separately with modifier -59 (distinct procedural service) attached.
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