tci General Surgery Coding Alert - 2011 Issue 6

Reader Questions: 60210 Thyroidectomy May Involve Additional Services

Question: How should we code the following note: Diagnosis: Locally advanced neoplasm of the thyroid gland with eminent airway obstruction, probably anaplastic, locally invasive and metastatic Procedure: Neck exploration and thyroid lobectomy, right side, exposure of trachea, tracheostomy, free interposition muscle flap using right sternocleidomastoid and strap muscles juxtaposed between the innominate vessels and tracheostomy. California Subscriber Answer: Coding from a list of procedures at the top of the operative report is always dangerous, because more specific information in the procedure description might change the code choices. In this case, a flap closure would be unusual for a thyroid...

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