Completion Thyroidectomy
Medical Specialty: EndocrinologyDescription:
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)
The surgeon performed a completion thyroidectomy on the right side. In other words, the surgeon removed the remaining right thyroid lobe after a prior left thyroid lobectomy, which is the definition of a completion thyroidectomy. In addition, the surgeon dissected out multiple right paratracheal (central neck) lymph nodes and sent them as a separate specimen. The surgeon also excised the old scar in an ellipse as part of the surgical approach.
CPT Codes for Thyroidectomy
Primary Procedure
60260-RT Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid (completion thyroidectomy)
Rationale
The documentation clearly states a previous left thyroid lobectomy. Now, the current procedure removes the remaining right thyroid lobe. As a result, this meets the definition of a completion thyroidectomy. Also, append RT for the right side.
Lymph Node Excision
38510-RT Biopsy or excision of lymph node(s); open, deep cervical node(s)
Rationale
The surgeon individually dissected and removed “multiple lymph nodes in the right paratracheal region” and sent them as a separate specimen. Therefore, the documentation supports separate reporting of the lymph node excision.
Modifier Considerations for Physician Billing
Report 60260-RT as the primary procedure and 38510-RT as the secondary procedure. However, check the NCCI edits first, because some payers bundle lymph node excision into the thyroidectomy. If the edits bundle it and the documentation supports distinct work, as it does here, append modifier 59 or XS (38510-RT-59), depending on payer preference.
Modifier 59 applies here for three reasons. First, the work involves separate anatomy (the thyroid versus the paratracheal nodes). Second, the record documents a separate specimen. Third, the procedure required distinct surgical effort.
Not Reported
Do not report the scar excision, because it is part of the surgical approach. Likewise, the flaps, closure, irrigation, and Surgicel are included. Finally, nerve monitoring is included unless another provider separately documents and performs it.
ICD-10-CM Codes
Primary Diagnosis
C73 Malignant neoplasm of thyroid gland
Both the preoperative and postoperative diagnoses document “multifocal thyroid carcinoma.”
Do Not Assign Based on This Documentation Alone
Do not assign C77.0 for lymph node metastasis. The provider did not document the nodes as metastatic, and the record does not confirm them as malignant. In addition, status codes such as a history of thyroid surgery are not necessary for the physician claim in this context.
HCPCS
The surgeon typically reports no separate HCPCS Level II code for items like Surgicel, Tegaderm, or the nerve monitoring endotracheal tube. Instead, these are generally packaged facility supplies, although facility outpatient coding rules may differ.
Not Separately Reportable (Typical)
The scar excision of the prior incision is usually part of the surgical approach for the thyroidectomy in the same operative field. For this reason, do not code it separately unless the documentation supports a distinct, separately billable reconstructive or scar revision service. Similarly, strap muscle dissection, flaps, irrigation, closure, and hemostatic agents are all included in the primary procedure.
Final Code Set (Physician Billing)
- 60260-RT
- 38510-RT-59 (if required per NCCI or payer edits)
- C73
Key Coding Insight (CPC Exam Tip)
This is a classic completion thyroidectomy scenario. A prior lobectomy plus removal of the remaining lobe equals 60260, not 60220 or 60240. Also, do not assume lymph node metastasis. Finally, do not automatically code a neck dissection (38720 or 38724) unless the record clearly documents one.