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Scenario Week of June 18, 2010:
View Current Scenario

Preoperative Diagnosis: Left thyroid mass, possible malignancy of the thyroid gland.

Postoperative Diagnosis: Carcinoma of the left thyroid lobe, possible Hürthle cell, possible papillary. Final diagnosis pending.

Operation: Left thyroid lobectomy followed by total thyroidectomy.

Anesthesia: General endotracheal.

Brief History: The patient noted a large lump in the left side of the neck. On evaluation by the primary physician, it was felt this was a solid lesion. It was cold on thyroid scanning. The patient was euthyroid. It was felt the patient needed surgical excision of this large mass by thyroid lobectomy, followed by subtotal or total thyroidectomy if carcinoma was identified.

Procedure: With the patient under satisfactory general anesthesia, the neck was prepped and draped in a sterile fashion.

A curvilinear incision was made along the skin lines above the sternal notch. The skin, subcutaneous tissue, and platysma were incised. Large subplatysmal flaps were created superiorly to the level of the thyroid notch and inferiorly to the level of the sternal notch. The strap muscles were split along the midline and retracted laterally. The large left thyroid lobe was dissected from its loose attachments laterally. The superior pole was taken down with ligatures of 2-0 silk and Hemoclips as needed. Mobilizing the lobe inferiorly similarly, the inferior pedicles were taken down with ligatures as well. Rotating the gland medially allowed visualization of the course of the recurrent laryngeal nerve. No parathyroid tissue was identified on the gland, as the dissection was kept directly on the thyroid gland surface. Hemoclips were used for hemostasis and control of any small tributaries. Following retraction of the entire gland off the trachea, the isthmus was divided with hemostatic ligatures of 2-0 silk.

The isthmus was sent for pathologic examination. The pathologist identified carcinoma in the gland with features suggestive of Hürthle cell carcinoma or papillary. With this information, it was elected to proceed with a total thyroidectomy.

A similar dissection was carried out on the right side with the superior pedicle being controlled first with ligatures of 2-0 silk and Hemoclips. Laterally and inferiorly, the loose attachments were taken down. The inferior pedicle was subsequently divided in a similar manner as the superior pedicle. Rotating the gland medially and identifying the course of the recurrent laryngeal nerve, a superior parathyroid gland was found, dissected off the thyroid gland, and left intact. (No parathyroid tissue had been identified thus far, and the specimen was removed.)

Hemostasis was again achieved with Hemoclips. A small tributary that was entered in the gland during the dissection was kept on top of the thyroid gland all the way through. Again, the peritracheal attachments were taken down with ligatures of 2-0 silk. The isthmus was also removed separately.

Both sides of the neck were checked for hemostasis, thoroughly lavaged, and pressure reevaluated. No evidence of bleeding or oozing was noted.

The wound was closed with the strap muscles then closed with 3-0 Vicryl. The platysmal flaps were closed with 3-0 Vicryl as well. The skin was closed with 4-0 Prolene subcuticular suture.

The patient tolerated the procedure well. The subcutaneous tissues and skin were infiltrated with local anesthetic. The patient was taken to the recovery room in satisfactory condition. The patient had good vocal cord function in the recovery room. A calcium level was to be drawn later in a few hours to evaluate for any hypocalcemia.

ICD-9-CM Diagnosis Code and Rationale
193    Malignant neoplasm of thyroid gland

Using the Neoplasm Table in ICD-9-CM, locate the appropriate anatomic site. In this case, “thyroid (gland)” and since the operative report indicates a malignancy, a code should be selected from one of the first three shaded columns denoted for malignancy primary, secondary, or carcinoma in situ. The neoplasm is not described as “in situ” nor is it a metastasis from another site; thus, it would be a primary malignant neoplasm and assigned to code 193. An instructional note listed with this code in the tabular index states “Use additional code to identify any functional activity”; however, in the scenario described above, no information is available to report an additional code.

CPT Procedure Code and Rationale
60240    Thyroidectomy, total or complete

Despite the fact that a unilateral lobectomy (60220) was initially performed, the definitive or final procedure was a complete thyroidectomy. CCI edits indicate that CPT code 60220 is an integral component of code 60240. However, use of an appropriate modifier may allow the edits to be bypassed if appropriate. In order to correctly report this service, the Correct Coding Initiative (CCI) Guidelines as published should be referenced. The guidelines are released yearly and the most recent is version 15.3. On pages xi and xii it states:

Although the emphasis in the manual is correct coding, there are certain types of improper coding that physicians must avoid.

Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must not unbundle the services described by a HCPCS/CPT code.

  • A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services…
  • A physician should not unbundle a bilateral procedure code into two unilateral procedure codes…
  • A physician should not unbundle services that are integral to a more comprehensive procedure.

Using the guidelines, it would therefore be inappropriate to unbundle this service when both procedures were performed at the same surgical session. If the surgical session had been closed and reopened later the same day or another subsequent day, then both procedures could be reported.

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