How To Use CPT Code 60210

CPT 60210 describes the partial thyroid lobectomy procedure, which involves the surgical removal of a part of one of the two lobes of the thyroid gland. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 60210?

CPT 60210 is used to describe the partial thyroid lobectomy procedure, which involves the surgical removal of a part of one of the two lobes of the thyroid gland. This procedure may or may not include the removal of the isthmus, the tissue connecting the two lobes of the thyroid gland in the middle.

2. Official Description

The official description of CPT code 60210 is: ‘Partial thyroid lobectomy, unilateral; with or without isthmusectomy.’

3. Procedure

1. The provider begins by making a standard neck incision, approximately 3-5 inches horizontally in the lower part of the front of the neck, just below the voice box.
2. They then separate the skin into upper and lower flaps and divide the overlying muscles.
3. During the procedure, the provider takes care to avoid injury to the adjacent recurrent laryngeal nerve, which innervates the vocal cord, as well as the thyroid arteries and veins that provide blood circulation to the thyroid.
4. The provider removes a part of the lobe of the thyroid gland, and may or may not remove the isthmus, depending on the specific case.
5. After achieving hemostasis, which is the stoppage of bleeding, the provider closes the overlying muscles and skin in layers.

4. Qualifying circumstances

CPT 60210 is performed on patients who require the surgical removal of a part of one of the lobes of the thyroid gland. The procedure may be indicated for various reasons, such as the presence of a localized benign nodule in an enlarged overactive thyroid in a patient with hyperthyroidism. The provider must ensure that the procedure is performed unilaterally, meaning on one side only.

5. When to use CPT code 60210

CPT code 60210 should be used when a partial thyroid lobectomy is performed, with or without the removal of the isthmus. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 60210, the provider must document the following information:

• Reason for the procedure, such as the presence of a benign nodule or other indications
• Details of the surgical approach, including the incision site and length
• Whether the isthmus was removed or not
• Any complications or unexpected findings during the procedure
• Details of the closure technique
• Post-operative instructions and follow-up plans

7. Billing guidelines

When billing for CPT 60210, ensure that the procedure is performed unilaterally, and that the documentation supports the use of this specific code. It is important to follow the guidelines provided by the payer and accurately report any additional services or procedures performed during the same encounter.

8. Historical information

CPT 60210 was added to the Current Procedural Terminology system on January 1, 1995. There have been no updates to the code since its addition.

9. Examples

1. A patient with hyperthyroidism undergoes a partial thyroid lobectomy to remove a benign nodule in the right lobe of the thyroid gland.
2. A provider performs a partial thyroid lobectomy with isthmusectomy on a patient with a suspicious thyroid nodule.
3. A unilateral partial thyroid lobectomy is performed on a patient with a large goiter causing compression symptoms.
4. A patient with a localized benign nodule in the left lobe of the thyroid gland undergoes a partial thyroid lobectomy without isthmusectomy.
5. A provider performs a unilateral partial thyroid lobectomy on a patient with Graves’ disease and an overactive thyroid gland.
6. A patient with a suspicious thyroid nodule undergoes a partial thyroid lobectomy with isthmusectomy to rule out malignancy.
7. A provider performs a unilateral partial thyroid lobectomy on a patient with a toxic adenoma causing hyperthyroidism.
8. A patient with a large thyroid nodule undergoes a partial thyroid lobectomy without isthmusectomy to relieve pressure symptoms.
9. A provider performs a unilateral partial thyroid lobectomy on a patient with a follicular adenoma in the right lobe of the thyroid gland.
10. A patient with a localized benign nodule in the left lobe of the thyroid gland undergoes a partial thyroid lobectomy without isthmusectomy.