Total Thyroidectomy
6024060252wRVU: 21.46 — With limited neck dissection60254wRVU: 27.71 — With radical neck dissection60260wRVU: 17.8 — Thyroidectomy with reoperation
Papillary/follicular thyroid carcinoma / Graves disease / multinodular goiter / indeterminate thyroid nodule (Bethesda IV/V/VI)
Same
Total thyroidectomy [with central neck dissection (levels VI)]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [thyroid carcinoma/Bethesda ___ nodule/Graves disease/multinodular goiter] presenting for total thyroidectomy. [Preoperative laryngoscopy confirmed [normal/impaired] vocal cord mobility bilaterally.] The risks, benefits, and alternatives were discussed with the patient, including risk of hypoparathyroidism and recurrent laryngeal nerve injury, and informed consent was obtained.
The thyroid gland was [enlarged/nodular/normal in size]. The [right/left/both] lobe(s) contained [a/multiple] nodule(s) measuring [___] cm. The thyroid was [not adherent / mildly adherent to surrounding structures]. The parathyroid glands were [identified bilaterally in normal anatomic position / with one gland autotransplanted]. The recurrent laryngeal nerves were [identified and preserved bilaterally]. [Central lymph nodes were sampled and sent for frozen section / enlarged central nodes were not identified.] [Additional findings or none].
The patient was brought to the operating room and placed supine with a shoulder roll for neck extension. General endotracheal anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics. [Intraoperative neural monitoring (NIM) endotracheal tube was placed with impedance confirmed bilaterally.]
The neck was prepped and draped in sterile fashion. A 4-5 cm transverse (Kocher) collar incision was made 2 cm above the sternal notch in a natural skin crease. The incision was carried through the skin and subcutaneous tissue including the platysma. Subplatysmal flaps were elevated superiorly to the thyroid cartilage and inferiorly to the sternal notch. The midline raphe between the strap muscles was incised and the strap muscles were retracted laterally exposing the thyroid gland.
The right lobe was addressed first. The middle thyroid veins were identified, ligated with [2-0 Vicryl ties / LigaSure], and divided to allow medial rotation of the right lobe. The superior thyroid vessels were individually dissected close to the thyroid capsule, individually ligated with [2-0 silk ties] [or with the energy device], and divided, taking care to identify and protect the external branch of the superior laryngeal nerve.
The right recurrent laryngeal nerve (RLN) was identified [in the tracheoesophageal groove / at the level of Berry's ligament / with neural monitoring confirming signal amplitude ___]. The nerve was dissected free from its entry into the larynx. The inferior thyroid artery branches were individually ligated close to the thyroid capsule, distal to the entry points of the parathyroid glands. The superior and inferior parathyroid glands were identified on the right side, their blood supply preserved, and they were reflected away from the specimen. Berry's ligament was divided. The right lobe was removed.
The procedure was repeated on the left side. The left RLN was identified [in the tracheoesophageal groove], confirmed with neural monitoring, and preserved. The left parathyroid glands were identified and their blood supply preserved. Berry's ligament was divided on the left. The left lobe and isthmus were removed en bloc.
[For central neck dissection: The pretracheal, paratracheal, and prelaryngeal lymph nodes (level VI) were dissected bilaterally from the hyoid bone superiorly to the innominate vessels inferiorly, and from carotid sheath to carotid sheath laterally. Lymph node packets were sent to pathology.]
The operative field was inspected. Hemostasis confirmed. A closed suction drain was placed [or omitted]. The strap muscles were reapproximated in the midline with [3-0 Vicryl]. The platysma was closed with [3-0 Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied. [Postoperative laryngoscopy was performed confirming bilateral vocal cord mobility.]
None
Total thyroid gland [with central neck lymph node dissection specimen] sent to pathology
Minimal (less than 30 mL)
None / [One small Blake drain]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Calcium and PTH will be monitored postoperatively.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Total thyroidectomy ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with ***. Preoperative laryngoscopy confirmed ***. Risks including RLN injury and hypoparathyroidism discussed. Informed consent obtained.
FINDINGS: Thyroid ***. Parathyroid glands identified bilaterally. RLN identified and preserved bilaterally. Central lymph nodes ***.
DESCRIPTION OF PROCEDURE:
Supine with shoulder roll. NIM tube placed, signals confirmed. General anesthesia. Surgical timeout per protocol.
Kocher collar incision. Subplatysmal flaps raised. Strap muscles divided in midline.
Right lobe: middle thyroid veins divided. Superior thyroid vessels ligated close to capsule protecting EBSLN. RLN identified *** and dissected to laryngeal entry. Inferior thyroid artery branches ligated distal to parathyroids. Parathyroids identified and preserved. Berry's ligament divided.
Left lobe: same technique. Both RLN confirmed on neural monitoring.
Total thyroid removed. *** central neck dissection. Hemostasis. Strap muscles closed. Platysma closed. Skin 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Thyroid to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Calcium and PTH monitored postoperatively.
Signed: .ME, .MYDEGREE
.TODAYVariants
With Central Neck Dissection (Level VI)
A prophylactic/therapeutic central neck dissection was performed. The level VI compartment was cleared from the hyoid bone to the innominate vessels and from carotid to carotid. The pretracheal, paratracheal, and prelaryngeal nodes were removed en bloc. Care was taken to identify and preserve the parathyroid glands and their vascular pedicles throughout. [One gland was devascularized and autotransplanted into the right sternocleidomastoid muscle in three to four small pockets, marked with a titanium clip.]
Hemithyroidectomy / Thyroid Lobectomy
A right/left thyroid lobectomy with isthmus was performed given [Bethesda III-IV nodule / solitary nodule / microcarcinoma without high-risk features per guidelines]. The ipsilateral lobe and isthmus were removed as described. The contralateral lobe was preserved. The ipsilateral RLN was identified and preserved. [Intraoperative frozen section of the specimen was obtained; result was consistent with ___ and the decision was made to proceed with/without completion thyroidectomy.]
Parathyroid Autotransplantation
One parathyroid gland on the [right/left] side was devascularized during the dissection. The gland was confirmed to be parathyroid tissue by pathology [or grossly identified by its characteristic appearance]. The gland was minced into 1-2 mm fragments and autotransplanted into three to four pockets created in the ipsilateral sternocleidomastoid muscle. The pockets were closed with [5-0 Prolene] and marked with a [titanium clip / Prolene suture] for future identification.
Charting Tips
- Document RLN identification specifically: where it was found (tracheoesophageal groove vs. Berry's ligament), that it was traced to its laryngeal entry, and preserved bilaterally. 'RLN preserved' without location is insufficient for medicolegal purposes.
- If neural monitoring was used, document baseline signal amplitude on each side, any intraoperative changes, and the signal at conclusion. 'Monitoring was used' without these data points offers no protection.
- Document each parathyroid gland individually: how many identified, which side, whether blood supply was intact, and the fate of each (preserved in situ, autotransplanted, or found on specimen). Permanent hypoparathyroidism with no gland documentation is indefensible.
- State that superior thyroid vessels were ligated close to the capsule to protect the EBSLN. An unrecognized EBSLN injury causes permanent loss of high-pitched phonation.
- Document preoperative laryngoscopy result by name to establish a baseline. If postoperative laryngoscopy was performed, document it. Voice changes without a documented preoperative exam create a gap.
Billing Tips
- Bill 60240 for total thyroidectomy (14.66 wRVU, 90-day global). Use for complete removal of both thyroid lobes and isthmus for benign or malignant disease.
- Bill 60252 for total thyroidectomy with limited neck dissection (21.46 wRVU) when central compartment (level VI) lymph node dissection is performed. Bill 60254 for total thyroidectomy with radical neck dissection (27.71 wRVU) when lateral compartment dissection is added.
- Central neck dissection (level VI) is bundled into 60252. Do not separately bill lymph node dissection codes when using 60252 or 60254. Document number of nodes retrieved and laterality of dissection.
- Intraoperative nerve monitoring (IONM) does not have a separate physician CPT. It is included in the surgical fee. Document monitoring performed, baseline waveforms, and any changes encountered for medicolegal purposes.
- 90-day global period: calcium/PTH monitoring, thyroid replacement initiation, and wound checks are bundled. Postoperative hypocalcemia management requiring an ED visit within the global period should be documented carefully, as acute treatment may be separately billable.