Parathyroid Coding and Billing

Fig. 43.1

A general overview of the reimbursement cycle . A physician documents the services and procedures provided along with their medical indications. This information is consolidated into diagnosis (ICD-9-CM/ICD-10-CM¹) and CPT² (current procedural terminology) numeric codes such as those for evaluation and management (E/M) and surgical services. The practice’s biller transmits the codes via a claim to the payer. After evaluating the claim, the payer returns the claim, in an explanation of benefits (EOB) format, to the practice. The patient is then notified for any and all remaining costs, when appropriate. The biller is responsible for monitoring payment status and ensuring timely and appropriate compensation. Original graphic

ICD-9-CM/ICD-10-CM

The USA is scheduled to adopt the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) on October 1, 2015. The new code set has over 50,000 more codes than ICD-9-CM. ICD-9-CM to ICD-10-CM translations are not always 1:1 and should be understood as approximations. Diagnosis code(s) should support the Current Procedural Terminology^® code(s) billed. Pertinent ICD-9-CM codes are listed next to the equivalent ICD-10-CM code in parentheses below.

252.01 (E21.0)—Primary hyperparathyroidism

227.1 (D35.1)—Benign neoplasm parathyroid gland [e.g., adenoma]

Example: For a resection of a parathyroid adenoma (CPT 60500), the primary diagnosis code is 227.1 (035.1) and 252.0 (E21.0) is a secondary diagnosis code.

194.1 (C75.0)—Malignant neoplasm, parathyroid gland

252.02 (E21.1)—Secondary hyperparathyroidism, non-renal

252.08 (E21.2)—Other hyperparathyroidism, tertiary hyperparathyroidism

259.3 (E34.2)—Ectopic hormone secretion, not elsewhere classified

Ectopic: Antidiuretic hormone secretion [ADH], hyperparathyroidism

255.10 (E26.9)—Hyperaldosteronism, unspecified

268.2 (M83.9)—Osteomalacia, unspecified

268.9 (E55.9)—Unspecified vitamin D deficiency, unspecified, avitaminosis D

268.0 (E55.0)—Active rickets

275.2 (E83.40)—Disorders of magnesium metabolism, hypermagnesemia, hypomagnesemia

275.3 (E83.30)—Disorders of phosphorous metabolism, familial hypophosphatemia, hypophosphatemia, vitamin D-resistant: osteomalacia, rickets

275.42 (E83.52)—Hypercalcemia

275.5 (E83.81)—Hungry bone syndrome

278.4 (E67.3)—Hypervitaminosis D

579.0 (K90.0)—Celiac disease

585.9 (18.9)—Chronic kidney disease, unspecified

586 (N19)—Renal failure, unspecified

588.81 (N25.81)—Secondary hyperparathyroidism (renal origin)

592.0 (N20.0)—Calculus of kidney (e.g., kidney stones)

733.90 (M89.9/M94.9)—Disorder of bone and cartilage, unspecified

733.93 (M84.36-)—Stress fracture of tibia or fibula (additional characters change depending on type of encounter and laterality of tibia or fibular—refer to ICD-10-CM resource)

781.7 (R29.0)—Tetany

791.9 (R82.99)—Other nonspecific findings on examination of urine (e.g., hypercalciuria)

Pertinent CPT Codes for Parathyroid-Related Services

The CPT codes pertinent to non-office visit parathyroid-related services include, but are not limited to, the codes listed below. The first two codes, 60500 and 60502, are the two most common codes used by parathyroid surgeons.

60500—Parathyroidectomy or exploration of parathyroid(s)

60502—Parathyroidectomy or exploration of parathyroid(s); re-exploration

31575—Laryngoscopy, flexible fiber optic; diagnostic

31599—Unlisted procedure, larynx [use for procedures that do not have a CPT code such as vocal cord medialization. Refer to CPT 2017 for a new CPT code for this procedure.]

60505—Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split, or transthoracic approach

+60512—Parathyroid autotransplantation (List separately in addition to code for primary procedure)

60520—Thymectomy, partial or total; transcervical approach (separate procedure)

60521—Thymectomy, partial or total; sternal split or transthoracic approach, without radical mediastinal dissection (separate procedure)

60699—Unlisted procedure, endocrine system

76536—Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation

78808—Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (e.g., parathyroid adenoma) [for example, radiopharmaceutical probe localization, intravenous injection]

83970—Parathormone (parathyroid hormone) [for example, PTH (C-terminal, intraoperative, intact, etc.]

+95940—Continuous intraoperative neurophysiology monitoring in the operating room, one-on-one monitoring requiring personal attendance, each 15 min (List separately in addition to code for primary procedure)

+95941—Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)

Modifiers

Modifiers are two-digit codes that are appended to a CPT code and provide more information to a payer about the code(s) reported. The most common modifiers used for parathyroid-related services are:

22—Increased procedural services: Use when the physician work required providing a service is substantially greater than typically required to provide the service. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). This modifier should be appended to a procedure code and not an Evaluation and Management (E/M) code .

26—Professional component: Use when reporting a radiology CPT code (e.g., 76536) and the physician provides only the radiological supervision and interpretation (S&I) portion of the service. The facility, or entity, that owns the equipment will report the radiology CPT code with modifier TC (technical component).

51—Multiple procedures: When multiple stand-alone procedure codes are performed at the same session by the same provider, the secondary lower valued procedure(s) may be identified by appending modifier 51. This modifier should not be appended to designated add-on codes such as 60512 (parathyroid autotransplantation) which are noted in CPT by the “+” symbol just prior to the code. Typically payers apply a multiple procedure payment reduction (MPPR) when modifier 51 is used; Medicare’s payment is reduced by 50% for overlapping pre-, intra-, and postoperative care.

59—Distinct procedural service: Occasionally it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. To support modifier 59, documentation must indicate that a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day actually was performed by the same individual. Use modifier 59 if another more descriptive modifier is not appropriate and the use of modifier 59 best explains the circumstances.

Evaluation and Management (E/M) Services and Supporting Documentation [2] (Refer to Tables 43.1, 43.2, 43.3, 43.4, 43.5, 43.6, 43.7, and 43.8)

Table 43.1

Progression of the elements required for each type of history

I. HPI	II. ROS	III. PFSH	IV. Type of history
Brief	N/A	N/A	Problem focused
Brief	Problem pertinent	N/A	Expanded problem focused
Extended	Extended	Pertinent	Detailed
Extended	Complete	Complete	Comprehensive

Adapted from 1997 Documentation Guidelines for Evaluation and Management Services; American Academy of Otolaryngology Head and Neck Surgery

To qualify for a given type of history, all three elements in the table must be met. A chief complaint is always indicated. HPI history of present illness, ROS review of systems, PFSH past family/social history

Table 43.2

Brief versus extended history of present illness (HPI)

I. HPI type	Description
Brief	Describe one to three elements of the HPI
Extended	At least four elements of the HPI, or the status of at least three chronic or inactive conditions

Adapted from 1997 Documentation Guidelines for Evaluation and Management Services; American Academy of Otolaryngology Head and Neck Surgery

Table 43.3

Review of systems

II. Review of systems
Constitutional
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/lymphatic
Allergic/immunologic

Adapted from 1997 Documentation Guidelines for Evaluation and Management Services; American Academy of Otolaryngology Head and Neck Surgery

Table 43.4

Review of systems (ROS)

ROS	Description
Problem pertinent	Positive responses and pertinent negatives for the system related to the problem should be documented
Extended	The patient’s positive responses and pertinent negatives for two to nine systems should be documented
Complete	At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented