How To Use CPT Code 60545

CPT 60545 describes the procedure of adrenalectomy, which involves the exploration or removal of one or both of the adrenal glands. 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 60545?

CPT 60545 can be used to describe the surgical procedure of adrenalectomy. This procedure involves the exploration or removal of one or both of the adrenal glands, which are small organs located above the kidneys. The adrenal glands secrete hormones that help regulate various bodily functions, such as the immune system, metabolism, blood sugar levels, and blood pressure. Adrenalectomy may be performed to address an overactive gland or glands, benign or cancerous tumors of the adrenal glands, or other diseases affecting these organs.

2. Official Description

The official description of CPT code 60545 is: ‘Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor.’ It is important to note that this code should not be reported in conjunction with code 50323, and for a bilateral procedure, code 60540 should be used with modifier 50. Additionally, if the procedure involves the excision of a remote or disseminated pheochromocytoma, codes 49203-49205 should be used. For a laparoscopic approach, code 60650 should be utilized.

3. Procedure

1. When performing adrenalectomy, the healthcare provider begins by appropriately prepping and anesthetizing the patient.
2. Based on the size, location, and invasiveness of the tumor, the provider makes an incision using one of three approaches: transabdominal, lumbar, or dorsal.
3. Once access to the area is gained, the provider explores the abdomen to assess the extent of the disease. If there are suspicious sites, the provider may decide to perform a biopsy and send the samples to pathology for immediate microscopic examination.
4. The provider then isolates the adrenal glands and identifies any tumors or diseased glands. If a diseased gland needs to be removed, the provider ties off the surrounding blood vessels to prevent excessive bleeding and proceeds with dissection.
5. If there is an adjacent retroperitoneal tumor, the provider carefully resects the mass along with a margin of uninvolved tissue and removes it together with the adrenal gland. The specimens are sent to pathology for examination.
6. After rinsing the abdominal cavity with a sterile saline solution, the provider closes the wounds and sutures the incisions.

4. Qualifying circumstances

Adrenalectomy is performed on patients with conditions such as overactive adrenal glands, benign or cancerous tumors of the adrenal glands, or other diseases affecting these organs. The procedure is typically carried out by a qualified healthcare provider who has the necessary expertise in performing adrenalectomy. The specific circumstances may vary depending on the patient’s condition and the provider’s clinical judgment.

5. When to use CPT code 60545

CPT code 60545 should be used when the provider performs adrenalectomy, either partial or complete, or exploration of the adrenal gland with or without biopsy. The procedure can be done through a transabdominal, lumbar, or dorsal approach. It is important to note that code 60545 should not be reported in conjunction with code 50323. Additionally, for a bilateral procedure, code 60540 should be used with modifier 50. If the procedure involves the excision of a remote or disseminated pheochromocytoma, codes 49203-49205 should be used. For a laparoscopic approach, code 60650 should be utilized.

6. Documentation requirements

To support a claim for CPT code 60545, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for adrenalectomy
• Specific surgical approach used (transabdominal, lumbar, or dorsal)
• Details of the procedure, including exploration, removal of one or both adrenal glands, and excision of adjacent retroperitoneal tumor if applicable
• Any biopsy performed and results if available
• Date of the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 60545, ensure that the procedure meets the criteria described in the official description. It is important to note that code 60545 should not be reported in conjunction with code 50323. For a bilateral procedure, code 60540 should be used with modifier 50. If the procedure involves the excision of a remote or disseminated pheochromocytoma, codes 49203-49205 should be used. For a laparoscopic approach, code 60650 should be utilized.

8. Historical information

CPT code 60545 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. It is worth noting that as of 2017, this procedure is listed under the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes adrenalectomy through a transabdominal approach to remove a benign tumor from one adrenal gland.
2. A healthcare provider performs adrenalectomy using a lumbar approach to explore both adrenal glands and remove a cancerous tumor.
3. An individual requires adrenalectomy through a dorsal approach to address an overactive adrenal gland.