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Become fully confident in your partial thyroidectomy coding.

The process of selecting the correct code for thyroid-related procedures presents coders with a multitude of challenges. This coding complexity escalates when the surgeon performs a partial thyroidectomy rather than a complete one.

Continue reading to learn more about how to correctly code thyroidectomy procedures with confidence.

Learn the Types of Thyroidectomies

There are two main types of thyroidectomy procedures:

Partial or hemi-thyroidectomy: When the surgeon performs a hemi-thyroidectomy or partial thyroidectomy, they are removing just one side of the thyroid. This procedure is normally carried out because a tumor or mass is affecting only one side. At the same time, the surgeon normally removes the pyramidal lobe, which holds the two sides of the thyroid together.

Removing only half of the thyroid is a lower-risk procedure and allows the patient to continue producing their own thyroid hormones. Code this surgery with 60220 (Total thyroid lobectomy, unilateral; with or without isthmusectomy).

Another coding option for a partial thyroidectomy, but one using a cervical approach, is 60271 (Thyroidectomy, including substernal thyroid; cervical approach).

Complete thyroidectomy: For patients who have previously had part of their thyroid removed, surgeons may need to perform a completion thyroidectomy later on. This is usually done after discovering cancer cells on the remaining portion of the thyroid. Due to previous scarring from the past surgery, this secondary procedure can prove challenging.

Code a complete thyroidectomy with 60260 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid). However, it’s important to read the documentation thoroughly to know when the procedure warrants 60260 and when you should instead code 60220. If the operative note itself isn’t clear, you may have to review the preoperative notes to determine whether this is a completion thyroidectomy, and use those notes to support the code in an audit request or query the practitioner.

Make note: Your surgeon may not use the exact words “completion” or “hemi” in their documentation of a thyroid procedure, which is why it’s important that you’re able to identify certain keywords in the notes that can lead you to the correct code.

Example: If the physician documents “thyroid lobectomy,” they are most likely referring to a hemi-thyroidectomy, and you will use code 60220.

If their notes mention “scarring” from a previous lobectomy, then they are most likely describing a completion thyroid lobectomy, and you’ll use code 60260 for that procedure.

Understand the Nuances of Goiter, Lesion, and Nodule Coding

The term “goiter,” as defined by the American Thyroid Association, refers to “the abnormal enlargement of the thyroid gland.” According to this definition, the description of a simple thyroid nodule also meets the criteria for a goiter. However, ICD-10-CM coding relies solely on the wording of the diagnosis. So even if some words have interchangeable meanings, it’s important not to code a particular symptom or disease if the ICD-10-CM Alphabetic Index does not lead you directly to it.

A documented thyroid lesion does not necessarily imply the presence of a nodule or goiter. While some coders are inclined to code “thyroid lesion” using E04.1 (Nontoxic single thyroid nodule) or E04.9 (Nontoxic goiter, unspecified), these would be incorrect. Instead, you will want to use E07.9 (Disorder of thyroid, unspecified) for thyroid lesions without any additional descriptive information.

To correctly code a single thyroid nodule, you will look to E04.1. However, you will want to factor in the diagnosis of hyperthyroidism as well. If you look at the E05.- (Thyrotoxicosis [hyperthyroidism]) code list, you will see that the correct option exists in code E05.10 (Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm).

Check out This Scenario

Now that you’ve reviewed the basics of thyroidectomy coding, put it all together with this scenario:

A 45-year-old patient presents with a large, symptomatic thyroid nodule that has been causing them discomfort and difficulty swallowing. After a series of tests, including an ultrasound and a fine needle aspiration biopsy, the nodule is determined to be benign but needs to be removed due to its size and the symptoms it’s causing. The patient is taken to the operating room where general anesthesia is administered. A transverse incision is made in the lower neck, and the strap muscles are separated to expose the thyroid gland. The surgeon then carefully dissects the thyroid tissue to isolate the nodule. The nodule, along with a portion of the thyroid tissue, is removed. The remaining thyroid tissue is preserved. The strap muscles are reapproximated, and the incision is closed with sutures. The patient tolerates the procedure well and is taken to the recovery room in stable condition. The excised nodule is sent to pathology for further examination.

You will use 60220 to report this procedure.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC