What is the appropriate CPT code for a subtotal thyroidectomy under general anesthesia, involving excision of the lower 1/3 of both the right and left lobes of the thyroid gland along with the isthmus (isthmic portion)?

CPT Coding for Subtotal Thyroidectomy with Isthmus Removal

The correct CPT code for a subtotal thyroidectomy involving the lower 1/3 of both right and left lobes plus isthmus removal is 60212.

Anatomical and Procedural Analysis

When coding thyroid procedures, it's essential to understand the exact anatomical structures removed and match them to the appropriate CPT code descriptions. In this case:

• The procedure involved removal of the lower 1/3 portion of both the right and left lobes
• The isthmus was also removed
• The procedure was performed under general anesthesia

CPT Code Options Analysis:

1. 60212: This code represents "Partial thyroid lobectomy, bilateral; with or without isthmusectomy"

   • This is the correct code as it specifically describes a bilateral partial removal of thyroid tissue with isthmus removal

2. 60210: This code represents "Partial thyroid lobectomy, unilateral; with or without isthmusectomy"

   • Incorrect because the procedure was bilateral (both lobes were partially removed)
   • Using modifiers -RT and -LT with 60210 would be inappropriate as this would indicate two separate unilateral procedures

3. 60225: This code represents "Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy"

   • Incorrect because this procedure did not involve total removal of one lobe

4. 60210-50: This would represent a bilateral partial thyroid lobectomy using the -50 modifier

   • Incorrect coding approach; when a specific bilateral code exists (60212), it should be used instead of applying the bilateral modifier to the unilateral code

Coding Rationale

The key distinction in this case is that portions of both lobes were removed, making this a bilateral procedure. CPT code 60212 specifically describes a bilateral partial thyroid lobectomy with or without isthmusectomy, which perfectly matches the procedure performed.

Common Pitfalls to Avoid

• Don't confuse partial bilateral thyroidectomy (60212) with unilateral procedures (60210)
• Avoid using the -50 modifier when a specific bilateral code exists
• Don't use -RT and -LT modifiers together when a bilateral code is available
• Remember that the isthmus removal is included in both 60210 and 60212 codes ("with or without isthmusectomy")

Accurate coding is essential for proper reimbursement and medical record documentation. In this case, the bilateral nature of the procedure, with partial removal of both lobes plus isthmus, clearly indicates that 60212 is the appropriate CPT code.