17.3 Endocrine, Hemic, Lymphatic, and Mediastinum
Key Takeaways
- Thyroid resection is selected by how much gland was removed (partial lobectomy 60210, total lobectomy 60220, total thyroidectomy 60240) and whether a listed neck dissection is included (60252 limited, 60254 radical); substernal sternal-split 60270 is not a typical ASC case.
- Parathyroid exploration is 60500; autotransplantation is add-on 60512. Fine-needle aspiration with ultrasound is 10005 (do not add 76942); thyroid core needle biopsy is 60100—not a second FNA code for the same nodule under Medicare NCCI.
- Lymph node biopsy or limited excision (38500 superficial open, 38505 needle, 38510 deep cervical, 38525 deep axillary) is not a lymphadenectomy (38740 superficial axillary, 38745 complete axillary).
- Bone marrow aspiration and biopsy at the same site and session is 38222, not 38220 plus 38221. Splenectomy (38100/38120) is rarely an outpatient payable procedure.
- Mediastinoscopy with biopsy of a mediastinal mass is 39401; mediastinoscopy with lymph node biopsies for staging (for example lung cancer) is 39402—do not add a separate 385xx node biopsy for those same nodes.
17.3 Endocrine, Hemic, Lymphatic, and Mediastinum
Quick Answer: Select thyroid codes by how much gland came out (60210 partial lobectomy, 60220 total lobectomy, 60240 total thyroidectomy) and by whether a listed neck dissection is in the same family (60252, 60254). Parathyroid exploration is 60500; autotransplantation is add-on 60512. Fine-needle aspiration (FNA) with ultrasound is 10005 without 76942. Thyroid core is 60100. Lymph node biopsy (38500, 38505, 38510, 38525) is not lymphadenectomy (38740, 38745). Same-site bone marrow aspiration and biopsy is 38222. Mediastinoscopy is 39401 (mass) versus 39402 (staging nodes). Splenectomy is rarely outpatient.
This independent OpenExamPrep section covers CPT endocrine (60000), hemic and lymphatic, and mediastinum services that a hospital outpatient department may still perform as SDS. NCCI Chapter VIII (Revision Date 1/1/2026) owns the 60000–69999 endocrine families. Hemic, lymphatic, and mediastinum codes live in the 30000 range and follow the same separate-procedure and same-approach logic used in the cardiovascular and respiratory surgery chapter. OpenExamPrep does not claim AAPC or CMS review of this teaching.
Why these systems still appear on a COC surgery item
Thyroid and parathyroid operations, cervical or axillary node sampling, image-guided FNA, bone marrow aspiration/biopsy, and mediastinoscopy for lymphoma or lung-cancer staging are the endocrine and hemic cases that actually reach SDS or the HOPD procedure suite. Complete axillary dissections and many substernal or sternal-split operations may still be inpatient-level. If the current OPPS status indicator is C, the procedure is not payable as outpatient—do not analogize from the CY 2026 musculoskeletal inpatient-only phase-out and assume every neck dissection is now an ASC case.
Facility reporting still has no professional global package. You code the resection, the sample, and the separately reportable add-on that CPT actually lists (such as 60512). You do not add an exploration code for looking at the recurrent laryngeal nerve on the way to the lobe that was removed.
Thyroid and parathyroid
Read the operative title and the body of the note for side, lobe versus isthmus versus total gland, and whether a neck dissection was performed as part of a listed thyroid-for-malignancy family.
| Documented thyroid work | Family | Common trap |
|---|---|---|
| Partial thyroid lobectomy, unilateral, with or without isthmusectomy | 60210 | Coding 60220 because the word total appears in "total removal of the nodule" |
| Total thyroid lobectomy, unilateral, with or without isthmusectomy | 60220 | Adding a contralateral 60220 without a documented contralateral lobe resection |
| Total or complete thyroidectomy | 60240 | Reporting 60220-50 for one total gland |
| Total or subtotal thyroidectomy for malignancy with limited neck dissection | 60252 | 60240 plus a separate limited lymphadenectomy that the 60252 family already describes |
| Same with radical neck dissection | 60254 | Unbundling 38724 from 60254 for the same radical neck |
| Completion thyroidectomy (removal of remaining thyroid) | 60260 | A second 60240 as if the first lobe were still present |
| Substernal thyroid, cervical approach | 60271 | Using sternal-split 60270 for a neck incision |
| Substernal thyroid, sternal split or transthoracic | 60270 | Forcing 60270 onto an ASC schedule |
Laterality applies to a unilateral lobectomy (LT/RT). A total thyroidectomy is the whole gland; do not append 50. Isthmusectomy performed with a listed lobectomy is included when the descriptor says so.
Parathyroidectomy or exploration of parathyroid(s) is 60500. Re-exploration is 60502. Exploration with mediastinal exploration, sternal split or transthoracic is 60505—another operation that is not a typical ASC line. Parathyroid autotransplantation is add-on 60512, listed separately in addition to the primary parathyroid procedure when the surgeon reimplants parathyroid tissue (often in muscle). Do not invent 60512 because frozen section mentioned a parathyroid fragment; the note must describe autotransplantation.
Approach work in the same neck incision—strap-muscle splitting, hemostasis, drain, routine identification of the recurrent laryngeal nerve—is included. A planned diagnostic laryngoscopy to check the cords after thyroidectomy is a different anatomic system; still run NCCI before adding it, and do not assume every "we looked at the cords" remark is a separately payable endoscopy.
Fine-needle aspiration versus core
FNA harvests cells with a fine needle for cytology. Core harvests a tissue cylinder. They are different CPT families, and imaging guidance is built into many FNA codes.
| Sampling method | First lesion | Additional lesion, same imaging method | Do not add |
|---|---|---|---|
| FNA without imaging guidance | 10021 | 10004 | 76942 |
| FNA including ultrasound guidance | 10005 | 10006 | 76942 |
| FNA including fluoroscopic guidance | 10007 | 10008 | A second fluoro guidance code |
| FNA including CT guidance | 10009 | 10010 | A second CT guidance code |
| Percutaneous core needle biopsy of thyroid | 60100 | Site-specific core families for other organs | 10005 plus 60100 for the same thyroid nodule on a Medicare NCCI claim |
| Needle biopsy of a superficial lymph node (not FNA cytology) | 38505 | Laterality when nodes are paired regions | 10005 if the note is FNA cytology of that node |
10005 already includes ultrasound guidance. 76942 is not a companion. FNA codes are reported per lesion, not per needle pass. Two passes into the same left thyroid nodule are still one 10005.
When FNA and core are both performed on the same lesion, same session, same imaging modality, Medicare NCCI policy does not allow both sampling codes as if they were unrelated surgeries. CPT parentheticals are narrower than that NCCI limitation. For a COC facility item, do not stack 10005 and 60100 on one nodule. If FNA is of a thyroid nodule and core is of a different structure (for example an axillary node) with documented distinct sites, NCCI may allow both after a modifier check (59 or XS) because they are not the same lesion.
A diagnostic thyroid ultrasound performed as a separate, medically necessary staging study of the whole gland is not automatically packaged into 10005, but a guidance ultrasound of the needle path is. Do not double-dip guidance.
Lymph node biopsy versus dissection
Biopsy or limited excision of node(s) is not a lymphadenectomy (regional node dissection).
| Documented node work | Family | Notes |
|---|---|---|
| Open biopsy/excision, superficial node(s) | 38500 | Cervical, inguinal, or axillary when the note is a limited excision, not a basin dissection |
| Needle biopsy, superficial | 38505 | Not FNA 10005 if the product is a core/needle biopsy of the node |
| Open, deep cervical node(s) | 38510 | Deeper than a readily palpable superficial node |
| Open, deep axillary node(s) | 38525 | Typical sentinel axillary node excision depth |
| Deep cervical with scalene fat pad | 38520 | Named extra work |
| Axillary lymphadenectomy, superficial | 38740 | A dissection, not 38525 |
| Axillary lymphadenectomy, complete | 38745 | Full axillary content as documented |
| Cervical lymphadenectomy, complete | 38720 | Not a thyroid code |
| Modified radical neck dissection | 38724 | Included in some thyroid-for-malignancy families |
Sentinel mapping adds 38792 (injection of radioactive tracer for identification of sentinel node) and/or add-on 38900 (intraoperative identification, including non-radioactive dye when performed) plus the excision code for the node that came out (38500 or 38525 as depth requires). If the frozen section converts the case to a complete axillary lymphadenectomy, report the dissection family (38745) for that basin; do not stack a separately paid 38525 for the same axillary sentinel node that became the start of the dissection. Laterality (LT/RT) belongs on paired basins.
NCCI: biopsy of node(s) in a basin is included in a lymphadenectomy of that same basin at the same encounter. Modifier 59/XS is for a different basin (for example a separate superficial inguinal node biopsy on the same date as an axillary dissection), not for "we sent the sentinel node as a specimen before finishing the axilla."
Bone marrow and spleen
Diagnostic bone marrow sampling was simplified so that both aspiration and biopsy at the same session no longer need two primary codes.
| What was performed, same site and session | Code | Do not report |
|---|---|---|
| Aspiration(s) only | 38220 | 38222 |
| Biopsy(ies) only | 38221 | 38222 |
| Biopsy(ies) and aspiration(s) | 38222 | 38220 plus 38221 |
CPT allows 38220 and 38221 together only when they are distinct sites or encounters (for example contralateral iliac crests) with a distinct-service modifier. Same iliac crest, same session, both techniques: 38222. Pathology interpretation of the marrow core is a professional pathology service (88305 family), not a second facility bone-marrow procedure code for the tap. Bilateral iliac sampling, when truly bilateral, follows modifier 50 instructions on 38220/38221/38222 rather than inventing a fourth marrow code.
Splenectomy, total, as a separate procedure is 38100; laparoscopic splenectomy is 38120. These are rarely hospital-outpatient or ASC cases. Partial splenectomy and repair families exist for trauma, which is even less likely to be an elective SDS. If the OPPS status indicator is C, do not report the splenectomy as a payable outpatient line. Do not analogize from laparoscopic cholecystectomy volume and assume laparoscopic spleen is a default ASC procedure.
Mediastinoscopy
Cervical mediastinoscopy is coded from what was biopsied, not from the word mediastinoscopy alone.
39401 is mediastinoscopy; it includes biopsy(ies) of a mediastinal mass (for example lymphoma) when performed. 39402 is mediastinoscopy with lymph node biopsy(ies) (for example lung-cancer staging). Do not add 38510 or 38500 for the mediastinal nodes already taken through the mediastinoscope. Do not pick 39401 for a staging procedure whose entire purpose was station-by-station node sampling without a named mediastinal mass biopsy. Do not pick 39402 for a discrete anterior mediastinal mass thought to be lymphoma when the descriptor you need is mass biopsy.
Older 39400 was deleted; do not resurrect it. Open mediastinotomy families (39000, 39010) are different operations and are not "a bigger mediastinoscopy." Sternal split for mediastinal parathyroid or substernal thyroid is the endocrine sternal-split code you already saw (60505, 60270), not 39402.
NCCI same-approach rule: the cervical incision, dissection to the pretracheal fascia, and hemostasis are included. A same-session diagnostic bronchoscopy is a different organ system but is still subject to PTP edits; only report it when it is a true separate procedure, not a brief look while the mediastinoscope is in the same field.
Mini-op-note (hospital SDS / HOPD)
Pre-op: right thyroid nodule, Bethesda V. Procedure: ultrasound-guided FNA, three passes, same right nodule; no core. Facility coding: 10005 only. Do not add 76942. Do not add 10006. Do not add 60100.
A second SDS example: total thyroidectomy for papillary carcinoma; central limited neck dissection as described by the 60252 family; no radical neck. Report 60240-versus-60252 from whether the limited neck dissection is the listed 60252 service. Do not add 38510 for those same central nodes.
A third example: iliac crest marrow aspirate and trephine biopsy, same side, same session, for suspected myeloma. Report 38222, not 38220 plus 38221.
A fourth example: cervical mediastinoscopy; biopsies of stations 4R and 7 for lung-cancer staging; no discrete mediastinal mass excised. Report 39402, not 39401 plus 38510.
A hospital outpatient marrow procedure documents aspiration and trephine biopsy of the left iliac crest at the same session. Which CPT reporting is correct?
An HOPD note documents ultrasound-guided fine-needle aspiration of a single left thyroid nodule, four needle passes. Which reporting is correct?
Cervical mediastinoscopy is performed for lung-cancer staging. The surgeon biopsies mediastinal lymph-node stations; no discrete mediastinal mass is excised. Which reporting is correct?