Completion Thyroidectomy
Medical Specialty: Endocrinology
Description:
Completion thyroidectomy with limited right paratracheal node dissection.
TITLE OF OPERATION:
Completion thyroidectomy with limited right paratracheal node dissection.
INDICATION FOR SURGERY:
A 49-year-old woman with a history of a left dominant nodule in her thyroid gland, who subsequently underwent left thyroid lobectomy and isthmusectomy, was found to have multifocal papillary thyroid carcinoma throughout her left thyroid lobe and isthmus. Consideration given to complete thyroidectomy. Risks, benefits, and alternatives of this procedure were discussed with the patient in great detail. Risks included but were not limited to anesthesia, bleeding, infection, injury to nerves, including vocal fold paralysis, hoarseness, low calcium, scar, cosmetic deformity, need for thyroid hormone replacement, and also need for further management. The patient understood all of this and then wished to proceed.
PREOP DIAGNOSIS:
Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.
POSTOP DIAGNOSIS:
Multifocal thyroid carcinoma and previous left thyroid lobectomy resection specimen.
PROCEDURE DETAIL:
After identifying the patient, the patient was placed supine in the operating room table. After the establishment of general anesthesia via orotracheal intubation with a number 6 nerve integrity monitoring system endotracheal tube, the eyes were protected with Tegaderm. The nerve integrity monitoring system endotracheal tube was confirmed to be working adequately and secured. The previous skin incision for a thyroidectomy was then planned and incorporated into an ellipse. The patient was prepped and draped in a sterile fashion. Subsequently, the ellipse around the previous incision was deformed. The scar was then excised. Subplatysmal flaps were raised to the thyroid notch and sternal notch, respectively. Strap muscles were isolated in the midline and dissected, and mobilized from the thyroid lobe on the right side. There was some dense fibrosis and inflammation surrounding the right thyroid lobe. Careful dissection along the thyroid lobe allowed for identification of the superior thyroid artery and vein, which were individually ligated with a Harmonic scalpel. The right inferior and superior parathyroid glands were identified and preserved, and the recurrent laryngeal nerve was identified and traced superiorly, then preserved. Of note is that there were multiple lymph nodes in the paratracheal region on the right side. These lymph nodes were carefully dissected away from the recurrent laryngeal nerve, trachea, and the carotid artery, and sent as a separate specimen labeled right paratracheal lymph nodes. The wound was copiously irrigated. The Valsalva maneuver was given. Surgicel was placed in the wound bed. Strap muscles were reapproximated in the midline with 3-0 Vicryl, and the incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin. The patient was extubated at the operating room table and sent to the postanesthesia care unit in good condition.
What was done (summary)
- Completion thyroidectomy (right side): The remaining right thyroid lobe was removed after a prior left thyroid lobectomy (this is the definition of a completion thyroidectomy).
- Paratracheal (central neck) lymph nodes removed (right): Multiple right paratracheal lymph nodes were dissected out and sent as a separate specimen.
- Old scar excised in an ellipse: Done as part of the surgical approach/re-entry.
CPT Codes
Primary Procedure
60260-RT
Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid (completion thyroidectomy)
Rationale:
- Documentation clearly states a previously left thyroid lobectomy
- The current procedure removes the remaining right thyroid lobe
- This meets the definition of a complete thyroidectomy
- Append RT for the right side
Lymph Node Excision
38510-RT
Biopsy or excision of lymph node(s); open, deep cervical node(s)
Rationale:
- “Multiple lymph nodes in the right paratracheal region” were:
- Individually dissected
- Removed
- Sent as a separate specimen
- This supports the separate reporting of lymph node excision
Modifier Considerations (Important for Physician Billing)
- 60260-RT → Primary procedure
- 38510-RT → Secondary procedure
Check NCCI edits:
- Lymph node excision may be bundled into thyroidectomy, depending on payer edits
- If bundled and documentation supports distinct work (which it does here), append:
38510-RT-59 (or XS depending on payer preference)
When to use modifier 59:
- Separate anatomical work (thyroid vs paratracheal nodes)
- Separate specimen documented
- Distinct surgical effort
NOT Reported
- Scar excision → Included in surgical approach
- Flaps, closure, irrigation, Surgicel → Included
- Nerve monitoring → Included unless separately documented/monitored by another provider
ICD-10-CM Codes
Primary Diagnosis
C73
Malignant neoplasm of the thyroid gland
Rationale:
- “Multifocal thyroid carcinoma” (preop and postop)
Do NOT Assign (based on this documentation alone):
- C77.0 (lymph node metastasis)
- Not documented as metastatic—nodes were removed but not confirmed malignant
- Status codes (e.g., history of thyroid surgery)
- Not necessary for the physician’s claim in this context
HCPCS
No separate HCPCS Level II code is typically reported for the surgeon for items like Surgicel, Tegaderm, or the nerve monitoring ETT; these are generally facility supplies/packaged. (Facility outpatient coding rules may differ.)
Not separately reportable (typical)
- Scar excision/ellipse of prior incision: Usually considered part of the surgical approach/re-entry for the thyroidectomy (same operative field) and not separately coded unless documentation supports a distinct, separately billable reconstructive/scar revision service.
- Strap muscle dissection/flaps/irrigation/closure/hemostatic agents: Included in the primary procedure.
Final Code Set (Physician Billing)
- 60260-RT
- 38510-RT-59 (if required per NCCI/payer edits)
- C73
Key Coding Insight (CPC Exam Tip)
This is a classic completion thyroidectomy scenario:
- Prior lobectomy + removal of remaining lobe = 60260 (NOT 60220/60240)
Also:
- Do not assume lymph node metastasis
-
- Do not automatically code a neck dissection (38720/38724) unless clearly documented