Otolaryngology Coding Alert

Heads up: "Functional," "selective," and "radical" refer to the same procedure.

Thinking you know thyroidectomy codes through and through may set you up for disaster. You really have to study the code descriptors and know the terminology associated with neck dissection to accurately code these procedures.

Tip: When coding for thyroidectomy procedures (60240-60271), keep a close eye on the code descriptors. "Many of them include all of the procedures that the otolaryngologist performed, so you won't have to report additional codes for the auxiliary services," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Decide Whether to Report Dissections

Challenge yourself with the following examples.

Suppose your otolaryngologist removes both thyroid lobes with the isthmus and pyramid lobe tissue. He also identifies and excises all enlarged lymph nodes. The malignancy has not spread significantly, so the otolaryngologist excises only a few selected lymph nodes. As a result, he performs a thyroidectomy with limited neck dissection. What CPT code(s) should you report, and should you report a separate code for the dissection?

Answer 1: You should report only 60252 (Thyroidectomy, total or subtotal for malignancy; with limited neck dissection). You should not report a separate code for the dissection. This code includes reimbursement for the thyroidectomy and the limited dissection.

What if the physician states in the operative note that she performed a "central neck dissection?" What would you code in this situation?

Answer 2: A central neck dissection is similar to the example above and represents a limited neck dissection, not a radical neck nor a modified radical neck dissection. So, if it is stated that a central neck dissection is performed with a total thyroidectomy, you would report 60252 (Thyroidectomy, total or subtotal for malignancy; with limited neck dissection).

Let's try another example. During a total thyroidectomy, an otolaryngologist dissects all the levels of lymph nodes and must sacrifice the spinal accessory nerve, jugular vein and sternocleidomastoid muscles to remove a malignant lymphatic chain. What CPT code(s) should you report, and should you report a separate code for the dissection?

Answer 3: In this case, report only the thyroidectomy with radical neck dissection with 60254 (Thyroidectomy, total or subtotal for malignancy; with radical neck dissection). By definition, you shouldn't separately report the radical neck dissection (38720, Cervical lymphadenectomy [complete]).

CPT, however, throws you a curve ball when your physician combines thyroidectomy with modified radical neck dissection. None of the thyroidectomy codes specify this combination, which you'll have to code out separately.

Suppose 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. What CPT code(s) should you report, and should you report a separate code for the dissection?

Answer 4: Because CPT doesn't include a code for the thyroidectomy with modified radical neck dissection, you should report 60240 (Thyroidectomy, total or complete) with 38724 (Cervical lymphadenectomy [modified radical neck dissection]). In a modified radical neck dissection, the surgeon dissects all levels of the lymph nodes on one side of the neck but spares the sternocleidomastoid muscle, the spinal accessory nerve, and the jugular vein. If your payer denies the 38724 as bundled, add modifier 59 (Distinct procedural service) to indicate that the modified radical neck dissection is separate procedure and appeal. Point out that you cannot use the bundled CPT code (60254) because the physician did not perform a radical neck dissection. Codes 60240 and 38724 reflect what the physician performed.

Don't forget to use modifier 50 (Bilateral procedure) if the physician performs the modified radical neck dissection bilaterally.

Watch Out for Other Terms

Although op report titles clue you into how to code a procedure, otolaryngologists may use several monikers for a modified radical neck dissection.

For instance, "functional neck dissection is the same as a modified radical neck dissection," Cobuzzi says. Another name your surgeon might use is selective neck dissection. The code for these is 38724.

Surprise: Instead of "neck dissections," CPT uses the terminology "lymphadenectomies," which fall under three codes:

• 38700 -- Suprahyoid lymphadenectomy
• 38720 -- Cervical lymphadenectomy (complete)
• 38724 -- Cervical lymphadenectomy (modified radical neck dissection).

Suppose, an otolaryngologist removes the lymph nodes as well as the sternocleidomastoid muscle, the spinal accessory nerve, and the internal jugular vein. This is a radical neck dissection (38720). Note that you should report 38700 when the surgeon removes the nodes above the hyoid only.