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Thyroid Surgery

Tracie Posted Wed 27th of February, 2019 13:47:23 PM
Our ENT surgeon performed a thyroid lobectomy, parathyroid exploration, and excision of paratracheal and retortracheal lymph nodes. The operative note states that the patient had a prior thyroid lobectomy on the opposite side years ago. The purpose of the surgery was to attempt to remove a parathyroid adenoma that had shown up on a scan, and the surgeon ended up removing the thyroid lobe, parathyroid tissue, and the lymph nodes. I'm torn on which codes to use for multiple reasons: 60252 would cover the lymph nodes being removed, but CPT describe that procedure as being "for malignancy", and this case is not malignancy. I am also considering 60260 since they had a prior thyroid lobectomy on the opposite side, but I would then need to report the lymph nodes separately. The operative note is below. Thank you for your assistance! NAME OF PROCEDURE: 1. Thyroid lobectomy right with nerve integrity monitor. 2. Parathyroid exploration. 3. Excision paratracheal lymph node. 4. Excision retrotracheal lymph node. PROCEDURE: This 55-year-old white female was taken to the operating room today and given general anesthetic. She was intubated with a NIM tube. Once she was intubated, the NIM tube was hooked up and working perfectly. The patient had a prior thyroid lobectomy on the left side years ago. Ultrasound showed no residual tissue and showed a few small nodules with the right remaining lobe. A sestamibi scan showed an adenoma on the right side. Her PTH was 77. Preoperatively, I explained to her that Dr. would assist. I also explained that we may have to end up removing the right lobe to gain access to find an adenoma in case we do not see it. She understood this. Complications such as hoarseness and hypocalcemia were explained. At this point, after the neck was prepped and draped, she recently had neck surgery on the left side, and we essentially extended the incision above the collarbone, over on the right side. This was injected with 1% Xylocaine with epinephrine. Next, an incision was made. We dissected through the skin, subcutaneous tissue, down through the platysma. A flap was elevated superiorly and inferiorly as customary for this type of procedure. The flap was then held in position with a thyroid retractor. Next, the strap muscles were isolated and split in the midline utilizing a Harmonic scalpel and bipolar cautery. Dr. help was quite important because of the all of the scar tissue from prior surgeries. At this point, we isolated the sternocleidomastoid muscle and we found the strap muscles and the right thyroid lobe and isthmus. We made a plane of dissection between the right lobe and the strap muscles and started working inferiorly, down in the inferior aspect of the thyroid. We inspected inferiorly and then we inspected along the entire length of the thyroid, up into the superior pole. We retracted the thyroid gland medially and found no evidence of an obvious enlarged parathyroid gland. At this point, the decision was made to remove the right lobe of the thyroid. Occasionally, parathyroid adenomas are inside the parenchyma of the thyroid. We isolated the superior pedicle, and utilizing a Harmonic scalpel, this was controlled. The middle thyroid vein was controlled with Harmonic scalpel and inferiorly the inferior vessels were controlled. At this point, we hugged the gland very closely until we did identify the recurrent laryngeal nerve very inferiorly, and followed this superiorly to where it entered the endolarynx. We dissected down to the posterior suspensory ligament, went anteriorly across the tracheal. Again, we found no evidence of any parathyroid mass at this point. We then dissected inferiorly until we could palpate the innominate and anteriorly toward the trachea, removed what appeared to be a paratracheal lymph node and sent this to the lab. Next, we went down medial to the carotid and found some lymph nodes which appeared to be some retrotracheal lymph nodes and these were removed and sent to the lab also. The patient is a know smoker. We removed other tissue that appeared to be parathyroid in color but we were not 100% certain that we identified what appeared to be the adenoma which was seen on the scan. We reviewed the scan again and the parathyroid mass was on the right thyroid bed area. We spent an awful lot of time looking inferiorly, laterally, superiorly, and medially around the entire thyroid bed and did an extremely thorough job of inspecting this area but did not see anything that looked like a parathyroid mass. At this point, Dr. then drew blood from the internal jugular and sent this to the lab, and the parathyroid level was exactly the as it was preoperatively. At this point, we felt it was time to close the incision, and we will admit her to an observation bed. In the morning we will dose her with isotope and mark the neck to see if we can get a better way to identify the parathyroid adenoma. Our thoughts are that this could be in the superior mediastinum or on the left side where the patient had prior surgery. The wound was irrigated. Valsalva maneuver was performed without any further bleeding and there was none. It was packed with surgical SNoW. Closure of the wound was then afforded with 3-0 chromic in the subcu layer after closing the straps with 3-0 chromic. Subu layer was closed with 3-0 chromic and skin approximated with running 4-0 Prolene. Blood loss was about 20 mL. The patient was taken to PACU and will be admitted to an observation bed. I discussed with radiology the dosing and she will be dosed in the morning at 7 o’clock and we will take her to surgery tomorrow about 10. The patient tolerated the procedure well.
SuperCoder Answered Thu 28th of February, 2019 02:19:21 AM

Hi Tracie,

 

AAE does not provide coding for operative reports and chart notes.

 

SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information.

 

Thanks!

Tracie Posted Thu 28th of February, 2019 07:54:39 AM
The operative note was included just to provide additional information after asking my question. Are you able to give an answer to my question without the operative report being included? My question above is as follows: Our ENT surgeon performed a thyroid lobectomy, parathyroid exploration, and excision of paratracheal and retortracheal lymph nodes. The operative note states that the patient had a prior thyroid lobectomy on the opposite side years ago. The purpose of the surgery was to attempt to remove a parathyroid adenoma that had shown up on a scan, and the surgeon ended up removing the thyroid lobe, parathyroid tissue, and the lymph nodes. I'm torn on which codes to use for multiple reasons: 60252 would cover the lymph nodes being removed, but CPT describes that procedure as being "for malignancy", and this case is not malignancy. I am also considering 60260 since they had a prior thyroid lobectomy on the opposite side, but I would then need to report the lymph nodes separately. Thanks.
SuperCoder Answered Fri 01st of March, 2019 03:16:54 AM

Hi Tracie,

 

I agree with you. It would be better to use CPT code 60260 in this case. CPT code 60252 is specific to thyroid removal for malignant condition and hence cannot be used since patient suffers from benign condition (parathyroid adenoma). You should also bill for removal of lymph nodes as well.

 

Hope, provided information would be helpful. 

 

Thanks,

Rahul  

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