If you are new to coding ENT procedures, the thyroidectomy section of the CPT manual can be daunting. There are several code options to choose from and all of the descriptions which are similar with minor variations between the descriptions can run together. To accurately code these procedures, you need to identify a few details from each operative report:
- Was the entire thyroid removed or only a portion?
- If less than the entire thyroid was removed, was only one lobe removed or were both lobes removed (in whole or in part)?
- Was any portion of the thyroid removed in a prior surgery?
- How did the surgeon reach the thyroid (e.g., through a neck incision or through an incision in the chest wall)?
Answering these four key questions will help you to select the correct CPT code. Let’s look at a couple of examples.
Example 1: After sterile prep and drape, a midline cervical incision was created and the strap muscles were divided. The laryngeal nerve was protected. We then approached the left lobe of the thyroid and freed the lobe from a superior to inferior direction until all attachments were released. We identified the left superior parathyroid gland and left it in place. Next, we reached the isthmus and divided the isthmus at the junction with the right lobe and the left lobe was removed in its entirety and sent for pathology.
If we look at our first question of whether the entire thyroid was removed or only a portion, we can see that only a portion of the thyroid was removed (see the words highlighted in green that indicate the left lobe was being freed up but the isthmus was divided from the right lobe of the thyroid). Because only a portion of the thyroid was removed, we will proceed to question #2 where we see that only the left lobe was removed and the entirety of that lobe was removed (see the words highlighted in red above).
Moving on to question #3, we have no mention that any portion of the thyroid was removed during a prior surgery so this question is not applicable in this case. Finally, for question #4, we know that the surgeon reached the thyroid through an incision in the middle of the neck (see words highlighted in blue above).
Based on the answers to the four questions above, we can determine that CPT code 60220 is the right code for this procedure. The description for this CPT code tells us that it is used to report a total lobectomy of the thyroid (removal of one lobe in its entirety) with or without removal of the isthmus (the small piece of tissue that is located between both thyroid lobes and connects them at the center of the thyroid). The thyroid is approached (meaning the surgeon gains access to the thyroid) through an incision in the neck.
Coding tip: When coding thyroidectomy cases, it may help to picture the thyroid as a butterfly with each lobe representing a wing and the isthmus representing the body of the butterfly. Using this analogy, in this case, CPT code 60220 includes removal of either the left or the right wing (but not both) and may include removal of the body of the butterfly attached to the wing being removed (though removing the body is not a requirement in order to make this the right CPT code based on the words “with or without” removal of the isthmus, or “the body” in the description).
Example 2: After sterile prep and drape, an incision was created overlying the sternum and a median sternotomy was performed. The muscles of the chest wall were retracted. The substernal thyroid was identified and freed up from the thoracic cavity. Then the remainder of the thyroid gland was mobilized including the left and right lobes. All parathyroid glands were left in situ and all attachments were released. The laryngeal nerve was protected throughout the case. Finally, the thyroid gland was removed in its entirety and sent to pathology.
If we look at our first question of whether the entire thyroid was removed or only a portion, we can see that the entire thyroid was removed (see the words highlighted in green indicating that both the right and left lobes were mobilized and the “entire” thyroid gland was removed). Because we know the entire thyroid was removed, we can skip question #2. Moving on to question #3, we have no mention of removal of a portion of the thyroid from a prior surgery so this question is not applicable in this case. Moving on to question #4, we can see that the surgeon created an incision over the sternum, performed a median sternotomy (or a division of the sternal bone), retracted (or pulled back) the muscles of the chest wall, and identified a “substernal” thyroid (see the words highlighted in blue).
Based on the answer to these questions, we can confirm that CPT 60270 is the appropriate CPT code for this case. This code includes removal of the entire thyroid gland including a portion of the gland that is substernal. Note that it will often be necessary to research some of the terms being used in the report and the code descriptions to arrive at the correct CPT code. For example, the word substernal means “under the sternum” (breaking the word down into its parts, sub means below and sternum refers to the breast bone); therefore, a “substernal thyroid” is a thyroid gland that extends into the chest below the sternum. If we look at the approach described by CPT 60270, sternal split is another term that is synonymous with “median sternotomy” (meaning the surgeon “split” or divided the sternal bone); on the contrary transthoracic means “across the thorax or the chest” which means that the surgeon uses an incision on the side of the chest overlying the ribs (known as a thoracotomy) and then dissects across/through the chest cavity to access the substernal thyroid gland. Whether the surgeon uses the median sternotomy approach (as he did in this case) or whether he uses the thoracotomy approach, if he is removing the entire thyroid including a portion of the gland that extends substernally (or below the sternum), CPT 60270 is our code.
As you can see, breaking down a complex surgical procedure like a thryoidectomy by researching unfamiliar terminology and answering key questions to understand what tissue was removed and how the procedure was accomplished simplifies the coding process and helps you to build confidence that you are selecting the correct CPT codes.
