How To Use CPT Code 60540

CPT 60540 describes the procedure of adrenalectomy, either partial or complete, or exploration of the adrenal gland with or without biopsy. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 60540?

CPT 60540 is used to report the exploration or removal of one or both adrenal glands. These glands are small organs located above the kidneys that secrete hormones to regulate various bodily functions. The procedure may involve different surgical approaches and may include a biopsy if necessary. Adrenalectomy is primarily performed to investigate or treat malignancy of the adrenal glands.

2. Official Description

The official description of CPT code 60540 is: ‘Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure).’ It is important to note that for a bilateral procedure, modifier 50 should be appended to the code.

3. Procedure

1. The provider begins by making an incision based on the size, location, and invasiveness of the tumor.
2. The procedure can be performed through a transabdominal approach, a lumbar approach, or a dorsal approach.
3. Once access is gained, the provider explores the abdomen to assess the extent of disease.
4. If there are suspicious sites, the provider may perform a biopsy and send the samples for immediate microscopic examination.
5. The provider then isolates the adrenal glands and identifies any tumors or diseased glands.
6. If necessary, the surrounding blood vessels of a diseased gland are tied off to prevent excessive bleeding.
7. The provider then dissects the glands and releases and dissects the attached tissue from surrounding structures.
8. If required, one or both of the adrenal glands are removed.
9. If there is an adjacent retroperitoneal tumor, the provider carefully resects the mass along with a margin of uninvolved tissue.
10. The specimen is sent to pathology for examination.
11. The abdominal cavity is rinsed with a sterile saline solution, and the wounds are closed and sutured.

4. Qualifying circumstances

CPT 60540 is performed when there is a need to explore or remove one or both adrenal glands. This procedure is typically indicated for patients with suspected or confirmed malignancy of the adrenal glands. It is important to note that the procedure should be performed by a qualified healthcare professional with the necessary expertise.

5. When to use CPT code 60540

CPT code 60540 should be used when the provider performs adrenalectomy, either partial or complete, or exploration of the adrenal gland with or without biopsy. It is important to ensure that the procedure is performed as a separate procedure and not as part of a larger, related service. Modifier 50 should be appended to the code when the procedure is performed bilaterally.

6. Documentation requirements

To support a claim for CPT 60540, the provider must document the following information:

• Patient’s diagnosis and indication for the procedure
• Details of the surgical approach used
• Extent of disease explored or removed
• Biopsy results, if performed
• Details of any additional procedures performed
• Any complications encountered during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 60540, it is important to ensure that the procedure is performed as a separate procedure and not as part of a larger, related service. Modifier 50 should be appended to the code when the procedure is performed bilaterally. It is also important to review payer-specific guidelines and consider appending modifier 59 if necessary to indicate that the procedure is distinct from other services performed on the same date.

8. Historical information

CPT 60540 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone changes, including a code change on January 1, 2010. It is important to stay updated with any changes or revisions to the code.

9. Examples

1. A patient undergoes adrenalectomy for the removal of a suspected adrenal tumor.
2. The provider performs exploration of the adrenal gland with biopsy to investigate a patient’s abnormal hormone levels.
3. A patient with confirmed adrenal malignancy undergoes complete adrenalectomy.
4. During a surgical procedure for renal tumor removal, the provider also performs exploration of the adrenal gland and partial adrenalectomy.
5. A patient with a retroperitoneal tumor undergoes adrenalectomy along with resection of the adjacent mass.
6. Exploration of the adrenal gland with biopsy is performed to investigate a patient’s unexplained weight loss and fatigue.
7. A patient with bilateral adrenal tumors undergoes adrenalectomy with the use of modifier 50.
8. During a surgical procedure for nephroureterectomy, the provider also performs exploration of the adrenal gland and partial adrenalectomy.
9. A patient with suspected adrenal malignancy undergoes adrenalectomy with radical total nephrectomy.
10. The provider performs exploration of the adrenal gland with biopsy to investigate a patient’s elevated blood pressure and abnormal hormone levels.