Thyroidectomies, Glossectomies, and Neck Dissections
Break down the intricacies of these complex procedures to select the right code.
By Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC
CPT® can be an incredible resource for coders, but when faced with a difficult operative report for a thyroidectomy, glossectomy or neck dissection, coders need every single resource in their coding arsenal. Here’s a few tips to help you select accurate codes for these complex procedures.
Get to Know Glossectomy Codes
Glossectomy is the surgical removal of all or part of the tongue, usually due to cancer. You’ll select from the 41120-41155 range when reporting this procedure.
Codes 41135 Glossectomy, partial, with unilateral radical neck dissection and 41145 … complete or total, with or without tracheostomy, with unilateral radical neck dissection refer to glossectomies with radical neck dissection. These procedures sacrifice the spinal accessory nerve, jugular vein and sternocleidomastoid muscles so the surgeon can remove the malignant lymphatic chain. Today, surgeons prefer to perform modified radical neck dissections whenever possible, so as not to jeopardize function of the spinal accessory nerve, jugular vein and sternocleidomastoid muscles. Because the codes for glossectomy were created years ago, the CPT® codebook does not provide for this modern and more common technique.
Modified radical neck dissections are more complex than radical neck dissections. To accurately report these services, coders should not report 41135 and 41145. Instead, report the appropriate code that refers to glossectomy without radical neck dissection (such as 41120, 41130, 41140 or 41150), along with 38724 Cervical lymphadenectomy [modified radical neck dissection]. Append modifier 59 to 38724 since the modified radical neck dissection is bundled into the codes that describe glossectomy without radical neck dissections.
For example, the surgeon finds that a patient with a painful left tongue lesion for the past four months has a 3.5-cm ulcerated lesion of the left lateral tongue and a 2.5-cm firm mass in the right midjugular region. She biopsies the tongue lesion, which turns out to be a squamous carcinoma. The physician performs a partial glossectomy and a modified radical neck dissection. For this procedure, the most accurate codes would be 41120 along with 38724-59. However, remember that some payers may require the coder to incorrectly code the service as 41135 for the partial glossectomy with radical neck dissection, even though the antiquated code (41135) does not reflect exactly what was performed. This is what happens when third-party payer reimbursement does not match pure coding rules or current surgical trends.
Base Thyroidectomy Code on Excised Components
During a thyroidectomy, the surgeon removes part or all of the thyroid gland. Many of the codes in this category include all of the services that the surgeon performed, so in some cases, the surgeon may describe several procedures but you’ll still only report one code. For example, suppose the otolaryngologist removes both thyroid lobes with the isthmus and pyramid lobe tissue. He also identifies and excises all enlarged lymph nodes. The malignancy has not spread significantly, so the otolaryngologist excises only a few selected lymph nodes. He then performs a thyroidectomy with limited neck dissection.
In this case, you should report 60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection only. This code includes reimbursement for the thyroidectomy and the limited dissection. In some situations, however, the coder may not be able to find a single code that covers both procedures that the surgeon performs.
For example, suppose an otolaryngologist removes both thyroid lobes. But when removing a malignant lymphatic chain, she manages to preserve the spinal accessory nerve, jugular vein and sternocleidomastoid muscles.
Because CPT® doesn’t include a code for the thyroidectomy with modified radical neck dissection, you should report 60240 Thyroidectomy, total or complete with 38724 Cervical lymphadenectomy [modified radical neck dissection]. Codes 60240 and 38724 are not bundled so a modifier is not needed. The modified radical neck dissection removes all levels of the lymph nodes of one side of the neck but spares the sternocleidomastoid muscle, the spinal accessory nerve and the jugular vein. This may also be referred to as a functional or selective neck dissection.
The parathyroids are glands that sit underneath and sometimes within the thyroid gland. Whereas the thyroid regulates the body’s metabolism, the parathyroids control the body’s calcium level. The physician may remove three of the patient’s four parathyroid glands, leaving one gland (or at least some tissue from one gland) to retain some parathyroid function. Practices should report 60500 Parathyroidectomy or exploration of parathyroid[s] for total and partial parathyroidectomies and for parathyroid explorations.
If the physician performs a parathyroidectomy during a thyroidectomy, do not separately report the parathyroidectomy because 60500, 60502 and 60505 are usually considered incidental to a thyroidectomy. When a physician performs a total parathyroidectomy, he may reimplant one gland in the forearm muscle to provide residual parathyroid function and easy access to the remaining gland after surgery. Report 60512 for this procedure, called parathyroid autotransplantation. Note that 60512 is an add-on code that should be reported in addition to the code for the main surgical procedure.
Some payers may deny 60512 when performed with a thyroidectomy, stating that they only pay for it when it is added on with a parathyroidectomy code (60500, 60502, or 60505). However, parathyroidectomy codes cannot be billed when a thyroidectomy is performed, creating a Catch 22. This may require the practice to appeal, which means you’ll have to write a detailed explanation to the third-party payer.
Neck Dissections Require Knowledge of Affected Muscles, Nerves and Veins
If the surgeon performs a radical neck dissection (38720), he removes the lymph nodes as well as the sternocleidomastoid muscle, the spinal accessory nerve and the internal jugular vein Modified radical neck dissections (38724) are unilateral procedures in which the surgeon dissects the neck, but spares the sternocleidomastoid muscle, the spinal accessory nerve and the internal jugular vein. The surgeon may also document a “functional” or “selective” neck dissection when he performs a modified radical neck dissection.
Report 38700 only when the surgeon removes only the nodes above the thyroid. Remember that a laryngectomy is included in a thyroidectomy and cannot be billed separately since the thyroid is wrapped around the larynx. Laryngectomy and intubation are also bundled and should not be reported separately. Appending modifier 59 will not separate this bundle even if the thyroid is being removed for a separate reason, (such as for a neoplasm of the thyroid).
Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, is the AAPC director of outreach programs.