How To Use CPT Code 60281

CPT 60281 describes the excision of a thyroglossal duct cyst or sinus, including its complete removal up to the back of the tongue and a portion of the hyoid bone. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 60281?

CPT 60281 can be used to describe the surgical removal of a thyroglossal duct cyst or sinus, including the complete excision of the cyst and tract up to the base of the tongue and a portion of the hyoid bone. This procedure is also known as the Sistrunk procedure. Recurrent cysts may occur if the previous surgery did not remove enough tissue or if the patient’s infection was not adequately controlled.

2. Official Description

The official description of CPT code 60281 is: ‘Excision of thyroglossal duct cyst or sinus; recurrent.’

3. Procedure

1. The provider ensures that the patient’s infection is controlled with antibiotics.
2. After the patient is prepped and anesthetized, the provider makes a small transverse incision in front of the neck over the cyst.
3. The provider separates the skin into upper and lower flaps and divides the platysma muscle.
4. The strap muscles are separated from the midline and retracted.
5. The provider isolates the cyst from the underlying tissues and removes it completely, including the tract up to the base of the tongue.
6. If present, the middle portion of the hyoid bone is also cut.
7. The removed tissue is sent for pathological investigation.
8. If the cyst has recurred, the provider may need to remove a larger amount of tissue.
9. Hemostasis is achieved, and a drain may be placed if necessary.
10. The overlying muscles and skin are closed in layers.

4. Qualifying circumstances

CPT 60281 is performed when there is a recurrent thyroglossal duct cyst or sinus. This may occur if the previous surgery did not remove enough tissue or if the patient’s infection was not adequately controlled. The procedure involves the complete excision of the cyst and tract up to the base of the tongue, as well as a portion of the hyoid bone.

5. When to use CPT code 60281

CPT code 60281 should be used when performing the excision of a recurrent thyroglossal duct cyst or sinus. It should not be used for initial excisions or for other types of cysts or sinuses.

6. Documentation requirements

To support a claim for CPT 60281, the provider must document the following information:

• Patient’s diagnosis of a recurrent thyroglossal duct cyst or sinus
• Details of the procedure, including the extent of excision and any additional tissue removal
• Date of the procedure
• Any complications or additional procedures performed
• Pathological investigation results, if applicable

7. Billing guidelines

When billing for CPT 60281, ensure that the procedure performed is the excision of a recurrent thyroglossal duct cyst or sinus. It should not be reported for initial excisions or other types of cysts or sinuses. There are no specific guidelines regarding reporting CPT 60281 with other codes. However, it is important to accurately document the extent of the excision and any additional procedures performed.

8. Historical information

CPT 60281 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient presents with a recurrent thyroglossal duct cyst. The provider performs a complete excision of the cyst and tract up to the base of the tongue, as well as a portion of the hyoid bone.
2. A patient’s previous surgery did not remove the cyst and tract completely, resulting in a recurrence. The provider performs a more extensive excision, removing a larger amount of tissue.
3. A patient’s thyroglossal duct cyst has recurred multiple times. The provider performs a complete excision of the cyst and tract, as well as a radical neck dissection.
4. A patient’s thyroglossal duct cyst has recurred, and there are concerns of mediastinal involvement. The provider performs an excision of the cyst and tract, as well as a mediastinal exploration.
5. A patient’s thyroglossal duct cyst has recurred, and there are concerns of mediastinal involvement and the need for a radical neck dissection. The provider performs an excision of the cyst and tract, a mediastinal exploration, and a radical neck dissection.