Otolaryngology Coding Alert

Follow a 5-step approach to find the right codes

Otolaryngology coding can hold surprises. For example, suppose your surgeon plans to perform a bilateral neck dissection with thyroidectomy and trachea resection but ends up having to also perform plate stabilization for access to the lymph nodes in the superior mediastinum. You can overcome this challenge with a thorough review of the documentation and careful use of modifiers. Still need convincing?

Consider the following op report, submitted to Otolaryngology Coding Alert by Julie Keene, CPC, an otolaryngology coding and reimbursement specialist at University ENT Specialists in Cincinnati. After you review the op note, code the procedures before you check out our expert advice below. Preoperative diagnosis: Medullary carcinoma of the right lobe of the thyroid, stage T4-A, N1-B, M0. Procedure overview: Another ENT previously started a total thyroidectomy on this patient but found that the cancer was eroding into the trachea, so he referred the patient to this surgeon. The new surgeon performed a right modified radical neck dissection with preservation of the spinal accessory nerve and sternocleidomastoid muscle, as well as a left selective neck dissection, removing the lymph node levels II through IV.
 
He also performed a right thyroidectomy, a resection of the right lateral trachea, and osteotomy of the right clavicle with plate stabilization for access to lymph nodes in the superior mediastinum.

Op Note: Trace the Surgeon's Work The pertinent details of the op report: We performed a modified radical neck dissection on the right neck, with preservation of the spinal accessory nerve and sternocleidomastoid muscle. We found that the internal jugular vein was involved by disease at level IV, and therefore sacrificed the internal jugular vein along with the rest of the neck contents. As we tracked the disease near the phrenic nerve, we saw that the disease was tracking down into the superior mediastinum and possibly involved the right subclavian vein.

We fractured the clavicle using a Gigli saw to offer better exposure to the vasculature in the superior mediastinum. We removed the lymph nodes that were tracking down along the carotid artery and jugular vein. We then performed a left neck dissection, removing lymph node levels II, III and IV.

We separated the fascia from the deep surfaces of the sternocleidomastoid muscle, which allowed us to remove the lymph node tissue from levels II, III and IV, bringing it anteriorly across the great vessels. Once we had it into the anterior aspect of temperature neck, we terminated the specimen and sent it to pathology.

We then started to remove the right lobe of the thyroid, which was easy to mobilize inferiorly. However, in the superior pole, there was obvious disease invading the trachea, so we had to cut into [...]