Otolaryngology Coding Alert

Thyroidectomies and other related excisions pose unique coding problems for otolaryngologists. Thyroidectomies are performed for malignancies as well as for non-malignant reasons (such as enlargement of the thyroid gland, or goiter). In the latter case, the surgeon may try to save enough of the gland to preserve thyroid function.
 
CPT includes several thyroid excision codes, ranging from simple aspiration and biopsy to total thyroidectomy. These include partial lobectomies, total lobectomies (which may be inappropriately dictated as partial thyroidectomy" " adding to the confusion) and "subtotal" thyroidectomies and lobectomies where most of the lobe or complete thyroid has been removed.
 
When neck dissections are performed coding is further complicated. CPT includes codes -- like other neck-based excisions due to malignancy -- that should be reported when a thyroidectomy and a neck dissection are performed during the same session. But unlike other procedures -- such as laryngectomies which are described by codes that either include radical neck dissection (31365) or do not (31360) -- thyroidectomies also include another category limited neck dissection that may be performed during the same session.
 
Limited and modified radical neck dissections are sometimes confused even though a limited dissection is a much simpler procedure involving only a few selected lymph nodes. Similarly a radical neck dissection does not accurately describe a modified radical which is a much more selective and complicated procedure.
 
Finally 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 a distinct CPT code.
 
Because there is such a variety of thyroidectomy and related codes terminology -- the code descriptions in CPT as well as the otolaryngologist's documentation -- is crucial when selecting the correct code (see story on page 60).

 
The first three codes in the excision section describe minor thyroid procedures -- aspiration and/or injection biopsy and excision:
 

60001 -- aspiration and/or injection thyroid cyst
 

60100 -- biopsy thyroid percutaneous core needle
 

60200 -- excision of cyst or adenoma of thyroid or transection of isthmus.
 
The second set of codes describes partial excisions:
 

60210 -- partial thyroid lobectomy unilateral; with or without isthmusectomy
 

60212 -- ... with contralateral subtotal lobectomy  including isthmusectomy
 

60220 -- total thyroid lobectomy unilateral; with or without isthmusectomy
 

60225 -- ... with contralateral subtotal lobectomy  including isthmusectomy.

 
These procedures are easy to confuse notes Lee Eisenberg MD an otolaryngologist in private practice in Englewood N.J. and a member of CPT's editorial panel and executive committee. "When you perform a total lobectomy or take out the whole lobe people sometimes mistakenly refer to that as a total thyroidectomy. There's also considerable confusion about what subtotal thyroidectomies and lobectomies are and how they differ from total or partial procedures."
 
When only a part of one thyroid lobe is excised (i.e. partial lobectomy) 60210 should be used. Sometimes however part of one lobe and the greater portion of the other lobe may be removed simultaneously. When this occurs 60212 should be reported.
 
Note: A subtotal lobectomy involves the excision of most of the thyroid lobe (about 90 percent). Similarly a subtotal thyroidectomy involves removal of the greater portion of the entire thyroid gland.
 
When a complete lobe is removed 60220 should be reported. 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 report 60225.

Tip 2: Use 60240 for  Thyroidectomies w/o Dissection

 
Total thyroidectomies are reported with six codes:
 

60240 -- thyroidectomy total or complete
 

60252 -- thyroidectomy total or subtotal for malignancy; with limited neck dissection
 

60254 -- ... with radical neck dissection
 

60260 -- thyroidectomy removal of all remaining thyroid tissue following previous removal of a portion of thyroid
 

60270 -- thyroidectomy including substernal thyroid gland; sternal split or transthoracic approach
 

60271 -- ... cervical approach.

 
For total thyroidectomy without neck dissection report 60240. Although some coding guides may instruct otolaryngologists to use 60240 only when the total thyroidectomy is performed for reasons other than cancer this is not accurate says Marge Hickey RN a past-president of the American Association of Head-Neck Nurses and an otolaryngology coding specialist in New Orleans.
 
Although the code descriptors for 60252 and 60254 specifically state that they are to be used only for malignancy this does not mean 60240 -- which does not refer to a particular diagnosis -- shouldn't be used if malignancy is present but no radical neck dissection is performed she says.
 
"The majority of total thyroidectomies are performed because of cancer " Hickey says. "Whatever the diagnosis if a total thyroidectomy is performed without an accompanying neck dissection 60240 is correctly used."

Tip 3: Bill Separately for Modified Radical Dissection

 
Thyroid tumors often are "indolent " or slow-growing. Even when this is the case the otolaryngologist may wish to perform "limited" neck dissection which involves removing a few enlarged lymph nodes only to make sure the cancer hasn't spread. In such cases 60252 which includes limited neck dissection should be reported Hickey says.
 
In the rare event of a "radical" neck dissection use 60254. More often however the otolaryngologist is likely to perform a "modified radical" neck dissection -- a more complex procedure than either the limited or radical dissections. A modified radical neck dissection removes more than a limited dissection but lacks the same levels of morbidity as a radical neck dissection (also known as a complete cervical lymphadenectomy). The latter involves sacrificing the spinal accessory nerve jugular vein and sternocleidomastoid muscles to remove a malignant lymphatic chain. Whenever possible otolaryngologists prefer to perform the modified radical procedure which removes the lymphatic chain but preserves the aforementioned nerve vein and muscles.
 
When a modified radical neck dissection is performed with a total thyroidectomy neither 60252 nor 60254 should be billed Eisenberg says. Instead report 60240 with 38724 (cervical lymphadenectomy [modified radical neck dissection]) says Susan Callaway CPC an independent coding and reimbursement specialist and educator in North Augusta S.C.
 
Correct billing for these procedures when performed together depends on the carrier. Because 60240 and 38724 are not bundled in the national Correct Coding Initiative some carriers may accept both procedures with no modifiers attached. Other carriers may want modifier -51 (multiple procedures) appended to the lesser-valued procedure (in this case 60240 with 27.43 relative value units [RVUs] versus 31.65 for 38724).
 
The third option is to append modifier -59 (distinct procedural service) to 60240. Some payers may try to recode the 38724 and 60240 inappropriately to "equal" either 60252 or 60254. Modifier -59 indicates that the thyroidectomy and neck dissection are distinct and should be paid separately.
 
Note: As the lesser-paid procedure 60240 should be listed after 38724 on the claim form.
 
If a thyroidectomy is accompanied by a limited or radical neck dissection on one side and a modified radical neck dissection on the other 38724 should be billed in addition to either 60252 or 60254. If a limited neck dissection is performed the procedures should be coded:
 

38724
 

60252-59.

 
Code 38724 is listed first. Modifier -59 is attached to 60252 because 38724 is a higher-valued procedure (31.62 vs. 31.65 RVUs respectively). If a radical neck dissection is performed however the order is reversed because 60254 has more RVUs (41.94) than 38724:
 

60254
 

38724-59.

 
In either case appropriate use of modifier -59 tells the carrier that a limited (or radical) neck dissection was performed on one side and a modified radical dissection was done on the other.
 
Although both the appropriate thyroidectomy code and 38724 include RVUs for opening and closing the patient this is more than compensated for by the multiple procedure rule by which the second procedure will be reduced by 50 percent Eisenberg says.
 
Because some carriers may inappropriately recode thyroidectomy/neck dissection claims coders should carefully check their explanation of benefits (EOBs) when payment for the service is received he adds.
 
Note: If a bilateral limited neck dissection is performed with a total thyroidectomy bill 60252 and 38700-59 (suprahyoid lymphadenectomy; distinct procedural service). If bilateral radical neck dissection is done 60254 and 38720-59 (cervical lymphadenectomy [complete]) should be billed.

Tip 4: Use 60260 for Removal of Remaining Tissue

 
When thyroidectomies are performed due to goiter or another unrelated malignancy the otolaryngologist will likely try to save part of the thyroid and preserve the gland's function by performing a partial or subtotal lobectomy or thyroidectomy (60210-60225). Subsequently however the remaining tissue may need to be removed.
 
For example if cancer is detected in the remaining thyroid tissue or nearby lymph nodes the otolaryngologist may need to remove the remaining tissue. This procedure is reported using 60260 (thyroidectomy removal of all remaining thyroid tissue following previous removal of a portion of thyroid).