Otolaryngology Coding Alert

We'll tell you which lymph-removal codes to report with 60252

Following a thyroidectomy, otolaryngologists may perform a limited, modified or radical neck dissection, so you should know how to report these procedures accurately to recoup pay for your physician's thyroidectomy and dissection services.
 
To help you master the coding variations for these procedures, we've provided the following scenarios in which the otolaryngologist performs a total thyroidectomy but the lymph-removal procedures differ.

Use 60252 for Thyroidectomy With Limited Neck Dissection

If you code an operative report that describes a total thyroidectomy and a limited neck dissection, you should report 60252 (Thyroidectomy, total or subtotal for malignancy; with limited neck dissection) for both operations.
 
Scenario 1: Your otolaryngologist removes both thyroid lobes with the isthmus and pyramid lobe tissue. He also identifies and excises all enlarged lymph nodes.
 
If the malignancy has not spread significantly, the otolaryngologist may excise only a few selected lymph nodes. In this case, he performs a thyroidectomy with limited neck dissection.
 
Coding for this combination operation is easy. CPT contains a single code that incorporates both the thyroidectomy and the limited neck dissection - 60252 - says Tara Normand, CPC, coder at Baton Rouge ENT Associates in Louisiana.

Assign One Code for Thyroidectomy, Radical Neck Dissection

 When your otolaryngologist performs a radical neck dissection in addition to a thyroidectomy, 60254 (... with radical neck dissection) includes both procedures. You shouldn't unbundle the procedures.
 
Scenario 2: During a total thyroidectomy, an otolaryngologist must sacrifice the spinal accessory nerve, jugular vein and sternocleidomastoid muscles to remove a malignant lymphatic chain.
 
In this case, report only 60254 (... with radical neck dissection) for the thyroidectomy with radical neck dissection. By definition, you shouldn't separately report the radical neck dissection (38720, Cervical lymphadenectomy [complete]), Normand says. 

Separately Code the Most Common Procedure 

When the surgeon performs a thyroidectomy and modified radical neck dissection, you should separately report the neck dissection.
 
Scenario 3: An otolaryngologist removes both thyroid lobes. But when removing a malignant lymphatic chain, she manages to preserve the spinal accessory nerve, jugular vein and sternocleidomastoid muscles.
 
Most thyroidectomies with neck dissections involve modified radical neck dissections. But CPT doesn't include a code for this combination procedure.
 
The National Correct Coding Initiative (NCCI) doesn't bundle neck dissections with thyroidectomies. Therefore, you should code each procedure using multiple-procedure rules, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee.
 
Use 60240 (Thyroidectomy, total or complete) for the thyroidectomy. You may use this code even if the patient doesn't have a malignancy" " Borden says.
 
But most total thyroidectomy-neck dissection cases involve malignant neoplasm he says. For the modified radical neck dissection you should report 38724 (Cervical lymphadenectomy [modified radical neck dissection]).
 
To indicate that the surgeon performs multiple procedures in the same session you should append modifier -51 (Multiple procedures) to the lesser-valued code. In this case the modified radical neck dissection (38724) has more relative value units (27.42) than the thyroidectomy (60240) (25.60 RVUs). So you should report 38724 60240-51 Borden says.
 
When your otolaryngologist performs thyroidectomy with a modified radical neck dissection correct billing depends on the payer. Since NCCI doesn't bundle the codes some payers may accept both procedures with no modifier Borden says. 
 
If a payer bundles the modified radical neck dissection with the thyroidectomy you should appeal the bundle. In the future use modifier -59 (Distinct procedural service) for that carrier and append it on the lower-valued procedure - the thyroidectomy (60240) Borden says.
 
You shouldn't expect many reimbursement problems with thyroidectomy-modified radical neck dissection claims. "I haven't seen any commercial-payer edits with 60240 and 38724 " Borden says

Use Modifier -59 for Different Sides

If surgery involves both sides you should report the appropriate code for each procedure.
 
Scenario 4: Your otolaryngologist performs a thyroidectomy with a limited neck dissection on one side and a modified radical neck dissection on the other.
 
Use 60252 for the thyroidectomy with limited neck dissection and 38724 for the modified radical neck dissection on the opposite side. Make sure to append modifier -59 to the lesser-valued code to indicate that the otolaryngologist performed the secondary procedure on a separate side from the primary operation Borden says.
  
When coding a limited thyroidectomy (60252) and a modified radical neck dissection (38724) you should list 60252 first and attach modifier -59 to 38724. In this case the modified radical neck dissection (38724) is the lesser-valued procedure. The limited thyroidectomy (60252) contains 32.80 RVUs. The modified radical neck dissection (38724) has 27.42 RVUs. You should report: