How To Use CPT Code 60522

CPT 60522 describes the procedure of thymectomy, which involves the removal of the thymus gland or a part of it. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 60522?

CPT 60522 is used to describe the surgical procedure known as thymectomy. This procedure involves the removal of the thymus gland, either partially or completely. The thymus gland is located in the base of the neck and plays a role in the development of white blood cells important for the immune system response. Thymectomy is typically performed to treat a benign or malignant tumor on the thymus gland, known as a thymoma. It may also be performed to treat the neuromuscular disease myasthenia gravis.

2. Official Description

The official description of CPT code 60522 is: ‘Thymectomy, partial or total; sternal split or transthoracic approach, with radical mediastinal dissection (separate procedure).’ This code is used when the provider performs a thymectomy using an incision on the sternum or one or both sides of the chest. The procedure involves the removal of a part or the entire thymus gland, along with adjacent mediastinal structures. It is important to note that for thoracoscopic thymectomy, a different CPT code, 32673, should be used.

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The provider makes an incision on the sternum or one or both sides of the chest, depending on the approach chosen.
3. The provider explores the chest and removes a part or the entire thymus gland, along with any adjacent affected mediastinal structures.
4. The surgical field is inspected to ensure no residual thymic tissue remains.
5. Chest tubes are inserted, and the site is closed in layers.
6. A sterile dressing is applied to the incision site.

4. Qualifying circumstances

Thymectomy is performed for patients with a benign or malignant tumor on the thymus gland (thymoma) or for those with the neuromuscular disease myasthenia gravis. The procedure is typically performed by a qualified healthcare professional using a sternal split or transthoracic approach. It may involve radical mediastinal dissection, which includes the removal of lymphatics and nonlymphatic structures in the neck.

5. When to use CPT code 60522

CPT code 60522 should be used when a thymectomy is performed using a sternal split or transthoracic approach, with radical mediastinal dissection. It is important to note that for thoracoscopic thymectomy, a different CPT code, 32673, should be used. CPT code 60522 should only be used when the procedure involves the removal of the thymus gland and adjacent mediastinal structures.

6. Documentation requirements

To support a claim for CPT code 60522, the following documentation is required:

• Patient’s diagnosis indicating the need for thymectomy
• Details of the procedure, including the approach used (sternal split or transthoracic) and whether radical mediastinal dissection was performed
• Date of the procedure
• Any additional procedures performed, such as the removal of a portion of the lung
• Any complications or unexpected findings during the procedure
• Signature of the performing healthcare professional

7. Billing guidelines

When billing for CPT code 60522, ensure that the procedure meets the criteria described in the official description. It is important to use the appropriate CPT code based on the approach used and the extent of the procedure. If additional procedures, such as the removal of a portion of the lung, are performed, a separate code may be reported or modifier 22 can be appended to CPT code 60522 to reflect the additional work.

8. Historical information

CPT code 60522 was added to the Current Procedural Terminology system on January 1, 1995. The code has not undergone any updates since its addition. It is worth noting that this procedure was added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes a thymectomy using a sternal split approach with radical mediastinal dissection for the treatment of a thymoma.
2. A thymectomy is performed on a patient with myasthenia gravis using a transthoracic approach with radical mediastinal dissection.
3. A provider performs a thymectomy using a sternal split approach with radical mediastinal dissection and removes a portion of the lung due to the presence of a malignant mediastinal thymoma.
4. A patient undergoes a thymectomy using a transthoracic approach with radical mediastinal dissection and removal of a portion of the lung for the treatment of a thymoma.
5. A thymectomy is performed on a patient with myasthenia gravis using a sternal split approach with radical mediastinal dissection and removal of a portion of the lung.