Otolaryngology Coding Alert

The parathyroids comprise a number of glands that sit underneath and, sometimes, within the thyroid gland. The  number of parathyroid glands in individuals varies from  two to six. Whereas the thyroid regulates the body's metabolism, the parathyroids control the body's calcium level.
 
Because the parathyroids are so close to the thyroid, they are often removed when a thyroidectomy is performed to remove malignancy. In such cases, the removal of the parathyroids is incidental to the thyroid excision and is not separately payable. At other times, the otolaryngologist, while performing a parathyroidectomy, finds a lesion on the thyroid gland that requires biopsy and/or excision. In these instances, the parathyroidectomy and the resulting thyroid excision procedure are both payable separately.
 
Also, after performing a parathyroidectomy, the otolaryngologist may transplant some of the parathyroid gland to a different anatomic site to preserve its function. This procedure, known as parathyroid autotransplantation, is payable separately even when thyroidectomy is also performed and the parathyroidectomy is included in the larger procedure.
 
The following codes describe parathyroid procedures:
 

60500 parathyroidectomy or exploration of parathyroid(s)

60502 re-exploration
 

60505 with mediastinal exploration, sternal split or transthoracic approach
 

60512 parathyroid autotransplantation (list separately in addition to code for primary procedure).
 
 
Often, otolaryngologists remove three or 3 1/2 of the patient's four parathyroid glands, leaving one gland (or at least some tissue from one gland) to retain parathyroid function and prevent hypoparathyroidism.
 
Code 60500 is used to report total and partial parathyroidectomies, says Sanford Archer, MD, an associate professor of otolaryngology at the University of Kentucky's College of Medicine in Lexington and chairman of the patient safety and quality improvement committee of the American Academy of Otolaryngology.
 
"The parathyroid organs are so small, the physician may believe they have all been excised, when, in fact, some tissue may have been left behind," he says. Either way, because parathyroid surgery can be quite meticulous, 60500 is also used to report parathyroid explorations.
 
When performing total thyroidectomies, otolaryngologists have to be careful to leave some parathyroid tissue so some function can be maintained. "The otolaryngologist tries to avoid removing parathyroid tissue unnecessarily (for example, if it is free of malignancy)," Archer says.
 
The parathyroidectomy should not be billed separately, because 60500, 60502 and 60505 are bundled with most thyroidectomy procedures in the national Correct Coding Initiative (CCI).
 
There are important exceptions. Sometimes, for instance, the otolaryngologist may find an unusual lesion on the thyroid during a parathyroidectomy for a malignant tumor. This occurs fairly often because thyroid pathology, although common, is also asymptomatic, and often there is no indication of the lesion until the thyroid is exposed. The physician then performs a biopsy and/or lobectomy or other thyroid excision, which may be billed separately with modifier -59 (distinct procedural service). 
 
To support modifier -59, the documentation of the session should include a note in a "Findings" section to let the carrier know that during the parathyroidectomy a lesion on the thyroid was observed, which  resulted in the decision to perform the thyroid excision. It may help to note that the otolaryngologist did not intend to perform a thyroidectomy until the parathyroidectomy was performed.

Parathyroid Autotransplantation

When a total parathyroidectomy is performed (on its own or with a thyroidectomy), the surgeon may reimplant one gland in the forearm muscle to provide residual parathyroid function and easy access to the remaining gland after surgery. This procedure, called parathyroid autotransplantation, is reported with 60512, an add-on code that should never be billed on its own.
 
Similarly, during the thyroidectomy, if the otolaryngologist also removes the parathyroid glands, autotransplantation may be performed. Even though the parathyroidectomy is bundled with the thyroidectomy, the autotransplantation is payable separately. The operative session is billed with the appropriate thyroidectomy code to report the thyroid excision, and 60512 is used to report the autotransplantation, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.
 
The fee for 60512 should not be reduced because, as an add-on code, it is exempt from multiple-procedure reductions, Cobuzzi says. She says that although CPT specifically designates 60512 as an add-on code, which means it is payable separately by definition, some carriers inappropriately bundle the procedure to whichever thyroid or parathyroid excision code it accompanies. For example, one practice says its state Medicare carrier denied 60512 billed with a thyroidectomy (60252, thyroidectomy, total or subtotal for malignancy; with limited neck dissection) because 60512 was considered by certain carriers an "independent" procedure and was therefore ineligible for payment.
 
Another carrier, noting that CPT links 60512 as an add-on code to certain codes (which do not include thyroidectomies but are bundled with them), has denied 60512 when performed with total thyroidectomy.
 
Such denials should be appealed, Cobuzzi says. In the first instance, the carrier should be informed that, as an add-on code, 60512 is not a separate procedure (if that is what the carrier meant by independent) and in fact is the opposite a service that cannot be billed on its own.
 
In the second example, an appeals letter to the carrier should explain that the parathyroid excision codes (60500, 60502 and 60505) they want to see before paying for 60512 are bundled with the thyroid excision procedure, and therefore 60512 should also be paid when performed with thyroid excisions, Cobuzzi says.