General Surgery Coding Alert

Question: How should we code the following note: Diagnosis: Locally advanced neoplasm of the thyroid gland with eminent airway obstruction, probably anaplastic, locally invasive and metastatic Procedure: Neck exploration and thyroid lobectomy, right side, exposure of trachea, tracheostomy, free interposition muscle flap using right sternocleidomastoid and strap muscles juxtaposed between the innominate vessels and tracheostomy. California Subscriber Answer: Coding from a list of procedures at the top of the operative report is always dangerous, because more specific information in the procedure description might change the code choices. In this case, a flap closure would be unusual for a thyroid lobectomy and tracheostomy unless the surgeon also removed tissue from the neck -- but the procedure list doesn't document a neck dissection. That said, you should code the case as follows, based on the procedure list you've given. The correct diagnosis is 193 (Malignant neoplasm of thyroid gland) for the thyroid cancer, [...]