Otolaryngology Coding Alert

Conflicting guidelines can be challenging to navigate when the physician uses a cervical approach.

When it comes to reporting thyroidectomies, coders have to ask themselves myriad questions before coming to the right code selection, and that’s even more true when the surgeon doesn’t perform a total thyroid removal. Add conflicting guidelines to the mix, and the issue can be even more puzzling.

Such is often the case when the otolaryngologist performs a thyroid lobectomy with substernal removal of the thyroid using a cervical approach. For this service, coders often struggle between selecting one of the following codes:

• 60220 (Total thyroid lobectomy, unilateral; with or without isthmusectomy)
• 60271 (Thyroidectomy, including substernal thyroid; cervical approach)

Check out the following steps that can help you pinpoint the most accurate code for these procedures.

Step 1: Check the Guidelines

As with coding anything that isn’t crystal clear, your first step should be to see where the governing bodies stand on guidance. This will typically start with reviewing the guidelines from the patient’s insurer. However, not many payers have a policy in writing about how to code when you perform a substernal lobectomy using the cervical approach.

If that’s the case for your situation, you’ll then turn to the AMA’s CPT^® guidelines to evaluate how to code when less than the entire thyroid is removed from the substernal space with a cervical approach.

When checking the CPT^® code book, you’ll see that a note under the descriptor for 60240 says “For thyroidectomy, subtotal or partial, use 60271.” However, if you read CPT^® Assistant from August 2020, the instructions say “Code 60271 would be reported only for a total thyroidectomy. When only one thyroid lobe with a substernal component is removed through a transcervical approach, report code 60220 with modifier 22 (Increased procedural services) appended for the additional work of removing the substernal component.”

The predicament: While one AMA source clearly indicates that you can report the service with 60271, the other specifically says to use 60220-22 for it, leading to further confusion. This brings you to step two.

Step 2: Consider the RVUs

When evaluating the two coding options, it can be a good idea to review the relative value units (RVUs) that Medicare assigns to both codes, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. She shares the following RVU breakdown, with two options for the possible reimbursement options for 60220-22, since payers won’t universally add a particular percentage to the payment and may vary on how much they’ll add to a 22-appended code:

“Without AMA guidance as to which code to use, we can conclude that if third-party payers only add 25 percent to the fee for 60220 for going into the substernal space for the thyroid lobectomy, the practice will be paid more by coding this service with 60271 as instructed under 60220 in the CPT^® code book,” Cobuzzi says. “But if the practice can negotiate a 50 percent or more increase in the value of 60220 for working in the substernal space, following the CPT^® Assistant guidance may be beneficial.”

If this is the case at your practice, show both options to the surgeon, along with the conflicting guidance, and confirm with the ENT which code they prefer to submit.

Step 3: Allocate Additional Time When Using Modifier 22

If you do decide to report your service with 60220-22, your practice will have to take extra time to ensure you collect for what you did.

“Extra resources are necessary for any 22-modified service, since third-party payers rarely pay these services on initial submission,” Cobuzzi said. “The increase that the practice receives is tied to the quality of the clinical documentation.”

To demonstrate the additional time and/or effort was required, you should include full documentation with every modifier 22 claim. The documentation should give a precise explanation — in clear language — of how much, and why, additional time, risk, and/or effort was necessary. Always be as specific as possible and compare the actual time, risk, effort, or circumstances to those typically needed or encountered. Avoid medical jargon and state in clear language the reason for the surgery’s unusual nature. The op report should clearly identify additional diagnoses, preexisting conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.

For example, Part B payer Novitas Solutions states in its modifier 22 policy, “You may report modifier 22 when work to provide a service is substantially greater than typically required. Documentation must support the substantial additional work and the reason for the additional work, which may include:

• Increased intensity
• Time
• Technical difficulty of procedure
• Severity of patient’s condition
• Physical and mental effort required

“Your documentation should provide our reviewers with a clinical picture of the patient; the procedures/services performed and support the use of modifier 22. Depending on the documentation, we may or may not allow additional reimbursement.”

“Usually, in order to be paid for a 22-modified claim, an appeal will have to be sent in to the payer because the standard fee schedule will be applied initially if the claim did not include the documentation,” Cobuzzi says. “An appeal with the documentation and a cover letter explaining the increased complexity will be needed to be sent into the payer in order to be paid additional money when using 60220-22.”

In cases when you report 60271, you should be paid correctly the first time, thus consuming fewer resources from your practice’s billing department, Cobuzzi adds.