AHA Coding Clinic® for HCPCS - 2021 Issue 1; For Your Information

Paralaryngeal neck mass

Patient who had a total thyroidectomy nine years ago, now presents for removal of a paralaryngeal neck mass with right thyroid tumor mass. Incision was made in the previous thyroidectomy scar. The platysmal muscle was divided and midline dissection was performed to dissect soft tissue off of the anterior tracheal wall all the way to the suprasternal notch. During soft tissue dissection the laryngeal nerve was being protected and a vascular mass along the tracheoesophageal groove on the right was identified. This mass extended laterally to the common carotid and internal jugular vein and deep to the omohyoid muscle, which was lysed in order to expose this mass. The mass was dissected off of the thyroid ala and cartilage, while protecting the great vessels and other structures. Additional soft, lymphatic and fatty tissue was dissected from different structures and areas including: the retro-esophageal and retro-pharyngeal areas, esophagus and pharynx. The pathology report indicates a diagnosis of multinodular goiter. Since the patient had a previous thyroidectomy and the diagnosis of goiter, would this be considered a thyroidectomy with removal of remaining tissue? Would an unlisted code be more appropriate for the procedure performed? ...

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