Otolaryngology Coding Alert

The August issue of Otolaryngology Coding Alert had an article about coding thyroid procedures that discussed the various procedures and how they differed. It also offered tips on coding thyroidectomies and neck dissections together, as well as removal of additional thyroid tissue after an earlier thyroidectomy.
 
Since then, readers have requested information on coding and billing several situations involving substernal thyroidectomies using a cervical approach:
 
Scenario No. 1: A transcervical approach is used to remove the substernal thyroid, coded 60271 (thyroidectomy, including substernal thyroid gland; cervical approach). Most of the time, only a unilateral hemithyroidectomy (also referred to as a total lobectomy) is performed because one lobe extends into the chest, causing symptoms. Sometimes, both lobes of the thyroid gland extend into the substernal space, so total thyroidectomy is required, again on both sides extending into the upper chest with a transcervical approach.
 
When coding this scenario, remember that 60271 is used to report a total thyroidectomy, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's editorial panel and executive committee. This is not as straightforward as it should be, because the code descriptor does not state either total"" or ""partial"" thyroidectomy.
 
Still" given that:
 
(a) elsewhere in the thyroid section CPT uses "thyroidectomy" to describe total thyroidectomies (partial thyroidectomies are referred to as lobectomies or isthmusectomies);
 
(b) all the codes surrounding 60271 describe total thyroidectomies; and
 
(c) Coders' Desk Reference states "The physician removes the thyroid including the substernal thyroid gland " it is reasonable to assume that 60271 describes a total thyroidectomy.
 
As a result in this situation 60271 should not be billed as:
 

A bilateral procedure using either modifier -50 (bilateral procedure) or -LT (left side) and -RT (right side).
 

An unusual service (modifier -22) that requires additional payment.
 
Note: If only one lobe is removed for a substernal thyroid the carrier may require that modifier -52 (reduced services) be appended to 60271.

Scenario No. 2: A total thyroidectomy is performed. One lobe is substernal the other is not substernal.
 
The difficulty here is related to the first scenario in that it also stems from incorrectly assuming that 60271 describes a partial thyroidectomy. If that were true 60220 (total thyroid lobectomy unilateral; with or without isthmusectomy) could be separately reported for the non-substernal lobe that is removed. Because 60271 describes a total thyroidectomy however no other code for the nonsubsternal lobectomy should be reported. In this situation 60271 may be reported even though only one of the two lobectomies performed was substernal.

Scenario No. 3: The patient is taken to the OR where a total thyroid lobectomy is performed. A week later pathology returns showing a carcinoma and removal of the patient's other lobe (i.e. a completion thyroidectomy) is recommended.
 
Some but not all completion thyroidectomies are reported with 60260 (thyroidectomy removal of all remaining thyroid tissue following previous removal of a portion of thyroid). The question here is should the completion thyroidectomy be reported with 60260 or should another 60220 be billed?
 
In this case the correct code is 60220 even though there may be more work when reopening the wound says Teresa Thompson CPC an otolaryngology coding and reimbursement specialist in Sequim Wa.
 
"Code 60260 should be used only when the otolaryngologist has to go back to the same side to remove additional tissue " she says. "If the patient has had a previous lobectomy years ago and now requires that the other lobe be removed 60220 should be reported." 
 
When otolaryngologists perform thyroidectomies on patients with goiter for instance they will try to preserve the gland's function by not removing all of it and instead perform partial or subtotal lobectomy or thyroidectomy. Later the remaining tissue may also need to be excised if for example cancer is detected.
 
In scenario 3 she says modifier -58 (staged or related procedure) would need to be appended to 60220 if the patient is still in the postoperative phase of the first lobectomy noting that "although the lobectomy was not preplanned (i.e. staged) it certainly is related and more extensive so it qualifies for modifier -58."
 
In this case the dictation in the operative report can have a big influence on the success of the claim Eisenberg adds: "The otolaryngologist needs to clearly note whether the tissue that was removed was from another lobe or leftover tissue from the original lobectomy." In this situation a findings section that indicates why the otolaryngologist had to remove the other side of the thyroid would also help he says (for more information see "'Findings' Section in Your Op Report Can Make Billing Easier " March 2000 Otolaryngology Coding Alert). 
  
Note: 60260 will not be reimbursed at an increased rate when billed using modifier -50 (bilateral procedure).