Covering Procedures Related to:
Thyroid Procedures
Thyroidectomy (Thyroid Gland Removal)
60210 – Total thyroidectomy, for malignancy
60212 – Total thyroidectomy, for benign disease
60220 – Hemithyroidectomy (removal of one lobe)
60225 – Subtotal thyroidectomy
AMA Guidelines
- Specify whether the thyroidectomy is total or partial. A total thyroidectomy involves removal of the entire thyroid, while hemithyroidectomy involves removal of one lobe.
- Indicate the reason for surgery (e.g., benign or malignant disease).
Thyroid Lobectomy
60240 – Lobectomy of the thyroid, unilateral
60250 – Lobectomy of the thyroid, bilateral
AMA Guidelines
- Document whether the lobectomy is unilateral or bilateral, as this affects code selection.
- Clarify the pathology (e.g., cancer, goiter, or benign condition).
Thyroid Biopsy
60100 – Fine needle aspiration biopsy of thyroid
60103 – Fine needle aspiration biopsy of thyroid, with ultrasound guidance
AMA Guidelines
Specify the biopsy method (e.g., fine needle aspiration) and whether ultrasound guidance is used.
Parathyroid Procedures
Parathyroidectomy (Parathyroid Gland Removal)
60100 – Fine needle aspiration biopsy of thyroid
60103 – Fine needle aspiration biopsy of thyroid, with ultrasound guidance
AMA Guidelines
Specify the biopsy method (e.g., fine needle aspiration) and whether ultrasound guidance is used.
Parathyroid Biopsy
60500 – Biopsy of parathyroid gland, percutaneous (needle biopsy)
AMA Guidelines
Document whether the biopsy is needle or open and the reason for biopsy (e.g., hyperparathyroidism).
Adrenal Gland Procedures
Adrenalectomy (Adrenal Gland Removal)
60540 – Adrenalectomy, unilateral
60541 – Adrenalectomy, bilateral, via laparoscopic approach
60550 – Adrenalectomy, bilateral, via open approach
AMA Guidelines
Specify whether the adrenalectomy is unilateral or bilateral and the approach (laparoscopic vs. open).
Document whether the adrenalectomy is performed due to malignancy or another condition.
Adrenal biopsy
60600 – Biopsy of adrenal gland, percutaneous or open
AMA Guidelines
Clarify whether the biopsy is percutaneous or open.
Provide the reason for the biopsy (e.g., evaluation of mass or abnormal hormone levels).
Pituitary Gland Procedures
Hypophysectomy (Pituitary Gland Removal)
60240 – Transsphenoidal hypophysectomy
60250 – Open hypophysectomy
AMA Guidelines
Document the approach (e.g., transsphenoidal vs. open).
Indicate the reason for surgery (e.g., pituitary tumor, Cushing’s disease).
Pituitary Tumor Resection
60220 – Removal of pituitary tumor via transsphenoidal approach
60225 – Removal of pituitary tumor via craniotomy (open)
AMA Guidelines
Specify the tumor type (e.g., benign adenoma, malignant tumor).
Document the approach (transsphenoidal vs. craniotomy).
Endocrine System Procedures Related to Hyperthyroidism and Hypothyroidism
Radioactive Iodine Therapy (Thyroid Cancer or Hyperthyroidism)
79005 – Radionuclide imaging and therapy of the thyroid
AMA Guidelines
Document the purpose of the therapy, whether for thyroid cancer or hyperthyroidism.
Thyroid Ablation Therapy
60272 – Radiofrequency ablation of thyroid nodule, unilateral or bilateral
AMA Guidelines
Specify whether ablation is unilateral or bilateral and the reason for the procedure (e.g., benign thyroid nodule or hyperthyroidism).
Modifier 22
Increased Procedural Services
Use when the procedure is more complex or takes significantly longer than usual.
Modifier 50
Bilateral Procedures
Use when the same procedure is performed on both sides (e.g., bilateral adrenalectomy or parathyroidectomy).
Modifier 51
Multiple Procedures
Use when multiple procedures are performed during the same session by the same provider.
Modifier 59
Distinct Procedural Service
Use when a procedure is separate and distinct from other procedures performed on the same day.
Modifier 78
Return to Operating Room for Related Procedure
Use when a patient requires a return to the operating room within the same postoperative period for a procedure related to the initial surgery.
Modifier 79
Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Use when a patient undergoes an unrelated procedure during the postoperative period.
Documentation and Reporting Requirements
General AMA Guidelines for Endocrine System Procedures:
Accurate Documentation: Ensure the procedure type, approach (e.g., laparoscopic vs. open), laterality (left or right side), and associated procedures (e.g., lymph node dissection) are documented.
Modifiers: Use modifiers when applicable, especially for bilateral procedures, additional services (e.g., biopsy), or increased procedural complexity.
Correct Code Selection: Select the appropriate CPT code based on the procedure performed. Include the specific reason for surgery (e.g., malignancy, hyperparathyroidism) in the documentation.
Example Scenarios
Scenario 1:
Total Thyroidectomy for Malignancy
CPT Code(s):Â
60210 – Total thyroidectomy, for malignancy
Modifier(s): None
Documentation: Confirm that the procedure is total thyroidectomy and is performed due to malignancy.
Scenario 2:
Laparoscopic Unilateral Adrenalectomy
CPT Code(s):Â
60541 – Laparoscopic adrenalectomy, unilateral
Modifier(s): None
Documentation: Clearly document that the procedure is unilateral and laparoscopic.
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Scenario 3:
Pituitary Tumor Resection (Transsphenoidal Approach)
CPT Code(s): 60220 – Removal of pituitary tumor via transsphenoidal approach
Modifier(s): None
Documentation: Specify the tumor type (e.g., adenoma) and approach (transsphenoidal).