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.

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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, and 519.8 (Other diseases of respiratory system, not elsewhere classified) for the airway obstruction.

For the procedure, report the following codes:

• 15732 -- Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)
• 60210 -- Partial thyroid lobectomy, unilateral; with or without isthmusectomy -multiple procedures
• 31600 -- Tracheostomy, planned (separate procedure) - multiple procedures.

Exploration included: You shouldn't separately code the neck exploration. Open procedures always include "exploration," unless it is very extensive or on the other side from the neoplasm,or unless it involves a separate excision such as a lymph node biopsy. Your brief note doesn't provide any documentation that would warrant an additional exploration charge.

Distinguish flap: Because the note indicates that this is a free flap, not a pedicle flap, the correct code is 15732. Remember that CPT® describes these muscle flap codes based on the donor site of the muscle, myocutaneous, or fasciocutaneous flap.