Otolaryngology Coding Alert

Question: During a parathyroidectomy for a malignant tumor, the otolaryngologist encounters a thyroid nodule that is suspicious for malignancy. Based on finding the unsuspected thyroid nodule, she performs a thyroid lobectomy with isthmusectomy. Should I report both the parathyroidectomy (60500) and the lobectomy (60220)?

Oklahoma Subscriber

Answer: Even though the National Correct Coding Initiative bundles parathyroidectomy (60500, Parathyroidectomy or exploration of parathyroid[s]) into thyroid lobectomy (60220, Total thyroid lobectomy, unilateral; with or without isthmusectomy), in this case you should report both the parathyroidectomy and the resulting thyroid excision procedure. The NCCI edits contain a "1" modifier indicator, which means you may use modifier -59 (Distinct procedural service) to override the bundle. To bill 60500-59, documentation must support billing the parathyroidectomy as a distinct procedure from the thyroid lobectomy.
 
Because the otolaryngologist, while performing a parathyroidectomy for a malignant tumor (194.1, Malignant neoplasm of parathyroid gland), finds a lesion on the thyroid gland (193, Malignant neoplasm of thyroid gland) that requires biopsy and/or excision, the thyroid lobectomy doesn't include the parathyroidectomy. Therefore, you should report 60220 and 60500-59.
 
But if, during a thyroidectomy, the otolaryngologist removes the parathyroids due to their close proximity to the thyroid, you shouldn't report the parathyroidectomy (60500). In these cases, the parathyroids' removal is incidental to the thyroid excision and is not separately payable.
 
To avoid denials for separately reportable 60500-59 claims, encourage your otolaryngologist to include documentation that shows the parathyroidectomy's distinct nature. For instance, a note in a "Findings" section stating that during the parathyroidectomy the otolaryngologist observed a lesion on the thyroid, which resulted in the decision to perform the thyroid excision, will help substantiate 60500 as a distinct procedure. You  may also want to include a statement that the otolaryngologist didn't intend to perform a thyroidectomy until she performed the parathyroidectomy.