If you are coding a tracheostomy procedure (CPT codes 31600-31610), you might be reading your operative report and suddenly see the physician mention the thyroid. This can be confusing at first, and this mention of a completely different organ that feels unrelated to the tracheostomy procedure may leave you feeling like you need to add an additional code for the work performed on the thyroid. However, this work is typically just part of gaining access to the trachea.
To explain, the thyroid isthmus (the cartilage that is in the middle of the thyroid gland and connects the two lobes) is located above the trachea, typically in the vicinity of the 3rd and 4th rings. To access the trachea and perform the tracheostomy, surgeons can sometimes retract the thyroid tissue (move it out of the way) without any incision into the trachea. However, when this is not possible, another common approach is to “divide” or “transect” the thyroid isthmus and then move the thyroid out of the way to gain access to the trachea. When a physician divides/transects the trachea, there is no disease or abnormality in the thyroid itself, and no part of the thyroid is actually being removed. The physician is simply dividing the thyroid and moving it out of the way to proceed with the planned procedure on the trachea. In this scenario, the division/transection of the thyroid is part of the approach to the tracheostomy which makes it bundle to the tracheostomy procedure.
To confirm the work on the thyroid is bundled, it is always helpful to look at guidelines from authoritative sources such as CMS and the AMA. In the National Correct Coding Initiative (NCCI) Policy Manual, which is published by CMS and provides guidance about procedures that bundle together, there are some helpful guidelines found in Chapter 1, section B: Coding Based on Standards of Medical/Surgical Practice: “Some procedures are integral in a large number of procedures…examples of procedures that are integral to a large number of procedures include…. Surgical approach including identification of anatomical landmarks, incision, evaluation of the surgical field, debridement of traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring.”
In this example with the thyroid and the trachea, the thyroid must be isolated (or moved out of the way) because it is limiting access to the surgical field (the trachea). Therefore, the work on the thyroid falls under this guideline and is bundled to the tracheostomy since it is part of the surgical approach. Notice that it is how the two procedures relate to each other that make the division/transaction of the thyroid bundled.
