Parathyroidectomy
Primary hyperparathyroidism with parathyroid adenoma [localized to the [right / left] [superior / inferior] gland on sestamibi scan and ultrasound]
Same
Focused parathyroidectomy / Four-gland parathyroid exploration with [single-gland / multigland] resection
[***, 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 to be parathyroid tissue. 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]. [No other significant findings were noted.]
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 tissue. 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 tissue. 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 tissue. 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.
Documentation & Reimbursement Considerations
- Report Parathyroidectomy as the primary service when it is the definitive operation performed.
- Use for standard bilateral neck exploration for primary hyperparathyroidism when four-gland exploration is performed.
- Use when the patient has had prior parathyroid or thyroid surgery and re-exploration is required. Document prior surgical history and scar tissue encountered.
- This is the only true add-on in this reporting option family; report it in addition to the primary parathyroidectomy code.
- Intraoperative PTH monitoring (IOPTH) is not separately billable by the operating surgeon. The surgical work of IOPTH guidance is captured within the primary parathyroidectomy code. 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 reporting apply. Approach does not change the reporting. Document that the exploration was directed by imaging and that IOPTH confirmed adequate drop (>50% from baseline).