RobinWomb72
New
It has always been my understanding that when a patient comes in for a a re-exploration of paraythyroid(s) with or without parathyroid surgery, it means they had a previous parathyroid surgery. I coded the below operative note from my surgeon as 60500. He wrote our Coding Education department insisting that the code should be 60502 since the patient had 2 previous neck surgeries (cervical fusion and carotid) and therefore the risk and difficulty of reopening that incision qualifies for 60502. Coding Education agreed with him on the basis of his argument and this article: "American Association of Endocrine Surgeons position statement on selected endocrine surgery billing codes and procedures: Addressing gaps in the current coding paradigm". I am not certain that this is enough to qualify this surgery below as 60502.
I can not find any definitive coding rules or guidelines on this scenario. I have searched CPT Assistant and various Medicare articles but I can not find any definitive information on what qualifies for re exploration of parathyroid(s) 60502. 3M has this description of 60502 which is not very detailed:
60502
The physician re-explores the parathyroids, glands adjacent to the thyroids. The physician exposes the thyroid via the previous incision. The parathyroid glands are identified and tissue is excised for separately reportable pathological examination. The parathyroid may be removed; usually a port remains following excision. The platysmas and skin are closed.
Below is a copy of the operative report in question minus personal details. Can anyone help with this? Are there any other resources out there regarding what qualifies for 60502? Is it REALLY any previous neck surgery that would qualify? Thank you for any input!
PRE-OPERATIVE DIAGNOSIS: Primary hyperparathyroidism with multinodular thyroid
POST-OPERATIVE DIAGNOSIS: Same
PROCEDURE: Reoperative neck surgery; right thyroid lobectomy with isthmusectomy, parathyroidectomy, intraoperative ultrasound, nerve monitoring, and parathyroid hormone testing.
SURGEON: ****
ASSIST: ****
ANESTHESIA: General endotracheal anesthesia
INDICATIONS: **** presenting with elevated calcium levels and elevated parathyroid hormone levels consistent with a diagnosis of primary hyperparathyroidism. She additionally has been noted to have multiple predominantly right-sided thyroid nodules. Given her history of osteoporosis, she was recommended to undergo parathyroid surgery and at the same time, we recommended right thyroid lobectomy given the nodular burden on the right side. After all risks and benefits were explained, she was consented for surgery.
DETAILS: Patient was brought into the operating room placed supine on table. Venodyne boots were placed and general anesthesia was induced after which the neck was extended with a soft shoulder roll. Neck ultrasound was performed. Ultrasound showed a nodular thyroid with the right lobe moderately enlarged. Posterior to the right lobe of thyroid, a hypoechoic structure consistent with an enlarged right superior parathyroid gland was seen. No additional enlarged parathyroid glands are seen. Her previous neck incision from cervical fusion was marked and extended over to the left side. The neck was then prepped and draped in the usual fashion.
A 6 centimeter incision was made and dissected through the subcutaneous tissue with electrocautery. Subplatysmal flaps were elevated and strap muscles were separated at the midline. Intraoperative parathyroid hormone level was drawn from the anterior jugular vein this level came back elevated at 87.3 pg/mL. We exposed right central neck compartment out to the carotid artery. Identified the right inferior parathyroid gland which appeared normal in size but did appear slightly firm. Decision was made to fully excise this gland. Frozen section of the fully excised right inferior parathyroid gland did show a 58 mg parathyroid gland that did appear hypercellular. We medialized the right lobe of thyroid and identified the recurrent nerve. Posterior to the recurrent nerve dunking under the crossing point of the inferior thyroid artery, we identified an enlarged right superior parathyroid gland. This gland was dissected and isolated on this pedicle. The pedicle was divided with the energy device. The gland was fully excised and submitted for frozen section which confirmed hypercellular parathyroid tissue weighing over 600 mg.
At this point, I decided to proceed with a right thyroid lobectomy. Right upper pole vessels were individually ligated with the energy device. At the completion of upper pole dissection, we noted strong cricothyroid twitch with proximal stimulation of the right external branch superior laryngeal nerve. The right lobe of thyroid was medialized and the recurrent nerve was identified. The course of the nerve was traced up into its insertion point. The right lobe of thyroid was isolated at the ligament of Berry which is then divided with 3-0 silk ties. We then divided the isthmus well to the left of midline. The right lobe of thyroid was then passed off the field.
15 minutes after excision of both of the right sided parathyroid glands, intraoperative parathyroid hormone level came down to from 19.3 pg/mL. At this point, I decided to cease further exploration. Note that the left central neck compartment was not explored. We confirmed hemostasis and laid Surgicel within the wound bed. We confirmed a strong right vagus nerve signal. Strap muscles were closed along the midline with interrupted 3-0 Vicryl. Platysma layer was closed with 3-0 Vicryl. Skin was closed with 4-0 Monocryl. Sterile dressings were applied. The patient was awoken from anesthesia and brought to recovery in stable condition.
Note that all needle, sponge, and instrument counts were correct. PA-C assistance required for tissue retraction and wound closure.
I can not find any definitive coding rules or guidelines on this scenario. I have searched CPT Assistant and various Medicare articles but I can not find any definitive information on what qualifies for re exploration of parathyroid(s) 60502. 3M has this description of 60502 which is not very detailed:
60502
The physician re-explores the parathyroids, glands adjacent to the thyroids. The physician exposes the thyroid via the previous incision. The parathyroid glands are identified and tissue is excised for separately reportable pathological examination. The parathyroid may be removed; usually a port remains following excision. The platysmas and skin are closed.
Below is a copy of the operative report in question minus personal details. Can anyone help with this? Are there any other resources out there regarding what qualifies for 60502? Is it REALLY any previous neck surgery that would qualify? Thank you for any input!
PRE-OPERATIVE DIAGNOSIS: Primary hyperparathyroidism with multinodular thyroid
POST-OPERATIVE DIAGNOSIS: Same
PROCEDURE: Reoperative neck surgery; right thyroid lobectomy with isthmusectomy, parathyroidectomy, intraoperative ultrasound, nerve monitoring, and parathyroid hormone testing.
SURGEON: ****
ASSIST: ****
ANESTHESIA: General endotracheal anesthesia
INDICATIONS: **** presenting with elevated calcium levels and elevated parathyroid hormone levels consistent with a diagnosis of primary hyperparathyroidism. She additionally has been noted to have multiple predominantly right-sided thyroid nodules. Given her history of osteoporosis, she was recommended to undergo parathyroid surgery and at the same time, we recommended right thyroid lobectomy given the nodular burden on the right side. After all risks and benefits were explained, she was consented for surgery.
DETAILS: Patient was brought into the operating room placed supine on table. Venodyne boots were placed and general anesthesia was induced after which the neck was extended with a soft shoulder roll. Neck ultrasound was performed. Ultrasound showed a nodular thyroid with the right lobe moderately enlarged. Posterior to the right lobe of thyroid, a hypoechoic structure consistent with an enlarged right superior parathyroid gland was seen. No additional enlarged parathyroid glands are seen. Her previous neck incision from cervical fusion was marked and extended over to the left side. The neck was then prepped and draped in the usual fashion.
A 6 centimeter incision was made and dissected through the subcutaneous tissue with electrocautery. Subplatysmal flaps were elevated and strap muscles were separated at the midline. Intraoperative parathyroid hormone level was drawn from the anterior jugular vein this level came back elevated at 87.3 pg/mL. We exposed right central neck compartment out to the carotid artery. Identified the right inferior parathyroid gland which appeared normal in size but did appear slightly firm. Decision was made to fully excise this gland. Frozen section of the fully excised right inferior parathyroid gland did show a 58 mg parathyroid gland that did appear hypercellular. We medialized the right lobe of thyroid and identified the recurrent nerve. Posterior to the recurrent nerve dunking under the crossing point of the inferior thyroid artery, we identified an enlarged right superior parathyroid gland. This gland was dissected and isolated on this pedicle. The pedicle was divided with the energy device. The gland was fully excised and submitted for frozen section which confirmed hypercellular parathyroid tissue weighing over 600 mg.
At this point, I decided to proceed with a right thyroid lobectomy. Right upper pole vessels were individually ligated with the energy device. At the completion of upper pole dissection, we noted strong cricothyroid twitch with proximal stimulation of the right external branch superior laryngeal nerve. The right lobe of thyroid was medialized and the recurrent nerve was identified. The course of the nerve was traced up into its insertion point. The right lobe of thyroid was isolated at the ligament of Berry which is then divided with 3-0 silk ties. We then divided the isthmus well to the left of midline. The right lobe of thyroid was then passed off the field.
15 minutes after excision of both of the right sided parathyroid glands, intraoperative parathyroid hormone level came down to from 19.3 pg/mL. At this point, I decided to cease further exploration. Note that the left central neck compartment was not explored. We confirmed hemostasis and laid Surgicel within the wound bed. We confirmed a strong right vagus nerve signal. Strap muscles were closed along the midline with interrupted 3-0 Vicryl. Platysma layer was closed with 3-0 Vicryl. Skin was closed with 4-0 Monocryl. Sterile dressings were applied. The patient was awoken from anesthesia and brought to recovery in stable condition.
Note that all needle, sponge, and instrument counts were correct. PA-C assistance required for tissue retraction and wound closure.