July 11, 2013
Our surgeon recently had a surgical procedure where the patient had a thyroid goiter and a parathyroid adenoma. Can I report both a thyroidectomy CPT code and the parathyroidectomy CPT code or are they bundled together?
The answer to your question really lies in your scenario. You note that the patient had two disease processes necessitating the two surgical procedures, thus both procedures are reportable. You may need to append Modifier 59 to the thyroidectomy procedure if your payor has an edit in place. Make sure the surgeons note documents the preoperative pathology and any diagnostic findings in the Indication for Surgery paragraph.
Please note that the two procedures would not be separately reportable if the two separate pathologies had not been present and during the thyroidectomy, the surgeon incidentally removed a parathyroid gland. In this instance, do not use report both services and do not use Modifier 59 to inappropriately override a payor edit.