Parathyroidectomy
60500
-
60502— Reoperation parathyroidectomy -
60505— With mediastinal exploration
Primary hyperparathyroidism with parathyroid adenoma [localized to right/left superior/inferior gland on sestamibi scan and ultrasound]
Same
Focused parathyroidectomy / Four-gland parathyroid exploration with [single-gland / multigland] resection
[Attending name], MD/DO
[Resident/PA name]
General endotracheal / local with MAC
The patient is a [age]-year-old [male/female] with primary hyperparathyroidism (calcium [___] mg/dL, PTH [___] pg/mL) presenting for parathyroidectomy. Preoperative localization with [sestamibi/4D-CT/ultrasound] demonstrated [concordant localization to the right/left superior/inferior gland]. Intraoperative PTH monitoring was planned. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
An enlarged [right/left] [superior/inferior] parathyroid gland weighing approximately [___] mg was identified and confirmed by frozen section as parathyroid adenoma. Intraoperative PTH dropped from a baseline of [___] to [___] pg/mL at 10 minutes after gland excision, confirming adequate resection (>50% drop from baseline). The remaining [three] parathyroid glands were [identified and confirmed to be normal in size / were not individually biopsied given adequate PTH drop]. [Additional findings or none].
The patient was brought to the operating room and placed supine with a shoulder roll for neck extension. [Anesthesia type] was induced. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics. A preoperative PTH level was sent immediately prior to incision ([___] pg/mL).
The neck was prepped and draped in sterile fashion. A 2-3 cm transverse collar incision was made in a natural skin crease on the [right/left] side of the neck. Subplatysmal flaps were elevated. The ipsilateral strap muscles were retracted laterally.
The thyroid lobe was gently retracted medially. The [right/left] [superior/inferior] parathyroid gland was identified in its expected anatomic location [posterior-superior to the thyroid lobe / at the inferior thyroid artery / in a paraesophageal position / in a thyrothymic ligament]. The gland was confirmed to be enlarged (estimated weight [___] mg) compared to a normal gland. The RLN was identified and preserved throughout.
The vascular pedicle of the adenoma was carefully ligated with [2-0 silk / hem-o-lok clips] and divided. The gland was excised in its entirety and sent for frozen section confirming parathyroid adenoma. A PTH level was drawn at 5 and 10 minutes after excision. [The level dropped from [___] to [___] pg/mL (>50% drop), meeting Miami criteria for cure.] [The remaining parathyroid glands were identified and confirmed to be grossly normal.]
Hemostasis was confirmed. [No drain was placed.] The strap muscles were allowed to fall back into position. The platysma was closed with [3-0 Vicryl]. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
Parathyroid adenoma (gland weight ___mg) sent to pathology for frozen and permanent section
Minimal (less than 10 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Calcium will be monitored postoperatively.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Primary hyperparathyroidism, *** parathyroid adenoma
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Focused parathyroidectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with primary hyperparathyroidism (Ca ***, PTH ***). Preoperative localization concordant at *** gland. Intraoperative PTH monitoring planned. Informed consent obtained.
FINDINGS: Enlarged *** parathyroid gland, estimated *** mg. Frozen section: parathyroid adenoma. PTH dropped from *** to *** pg/mL at 10 min (>50% drop, Miami criteria met). RLN identified and preserved.
DESCRIPTION OF PROCEDURE:
Supine with shoulder roll. *** anesthesia. Baseline PTH *** pg/mL. Surgical timeout per protocol.
*** cm collar incision on *** side. Subplatysmal flaps raised. Strap muscles retracted. Thyroid lobe retracted medially. *** parathyroid adenoma identified at ***. RLN identified and preserved. Vascular pedicle ligated and divided. Gland excised. Frozen section confirmed parathyroid adenoma. PTH drop confirmed cure.
Hemostasis. Platysma closed with 3-0 Vicryl. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Parathyroid adenoma 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.
Signed: .ME, .MYDEGREE
.TODAYVariants
Four-Gland Exploration (Multigland Disease)
[Preoperative localization was non-localizing / intraoperative PTH failed to drop adequately after single-gland resection.] A bilateral four-gland exploration was performed through an extended collar incision. All four parathyroid glands were identified ([superior left, inferior left, superior right, inferior right]). The [two/three] enlarged gland(s) were excised. [For 3.5-gland resection: a portion of the most normal-appearing gland was preserved on its vascular pedicle as a remnant, marked with a hem-o-lok clip.] Intraoperative PTH confirmed an adequate drop after resection.
Ectopic or Intrathyroidal Adenoma
The expected anatomic location of the [superior/inferior] parathyroid gland on the [right/left] was explored but no abnormal gland was found. Systematic exploration was performed including the thyrothymic ligament, thymus, carotid sheath, and retroesophageal space. [The gland was found in the [thyrothymic ligament / upper thymus / retroesophageal position] and excised.] [An intrathyroidal adenoma was suspected; a right/left thyroid lobectomy was performed and the adenoma was identified within the thyroid parenchyma at pathology.]
Secondary/Tertiary Hyperparathyroidism (CKD)
The patient had secondary hyperparathyroidism in the setting of chronic kidney disease / end-stage renal disease. A 3.5-gland parathyroidectomy was performed. All four glands were identified and confirmed enlarged. Three glands were excised in their entirety. The most normal-appearing remaining gland was partially resected, leaving a remnant estimated to weigh 40-60 mg on its vascular pedicle, marked with a hem-o-lok clip. Intraoperative PTH confirmed an adequate drop.
Charting Tips
- Document the Miami criteria result explicitly. State the pre-excision baseline PTH, the 10-minute post-excision PTH, and whether the 50% drop criterion was met. This is the operative standard for cure verification and must be in the note.
- Document the approximate weight of the excised gland. Normal parathyroid gland is 30-60 mg; an adenoma is typically >100 mg (often 500-1500 mg). The weight contextualizes the pathology and supports the diagnosis.
- Document the recurrent laryngeal nerve identification for parathyroidectomy. The nerve is at risk, particularly during inferior parathyroid dissection, and its explicit documentation is the same standard as for thyroidectomy.
Billing Tips
- Bill 60500 for parathyroid exploration (15.21 wRVU, 90-day global). Use for standard bilateral neck exploration for primary hyperparathyroidism when four-gland exploration is performed.
- Bill 60502 for re-exploration of parathyroids (20.62 wRVU). Use when the patient has had prior parathyroid or thyroid surgery and re-exploration is required. Document prior surgical history and scar tissue encountered.
- Bill 60505 for parathyroid exploration with mediastinal exploration (22.48 wRVU) when an ectopic gland requires sternal or mediastinal dissection.
- Intraoperative PTH monitoring (IOPTH) does not have a separate physician CPT code. It is considered bundled. Document pre- and post-excision PTH values in the operative note for clinical and quality purposes.
- For focused parathyroidectomy guided by preoperative imaging (sestamibi/4DCT), the same codes apply. Approach does not change the CPT. Document that the exploration was directed by imaging and that IOPTH confirmed adequate drop (>50% from baseline).