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2025 CPT code 60545

Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal; with excision of adjacent retroperitoneal tumor.

Refer to CPT coding guidelines for proper coding of adrenalectomy procedures.Pay close attention to the specific approach used and whether an adjacent retroperitoneal tumor was excised, as these factors determine the appropriate code selection.

Modifiers may be applicable in certain situations. For example, modifier 52 (Reduced Services) may be used if the procedure was not completed as planned.

Medical necessity for this procedure is determined by the underlying condition affecting the adrenal gland(s). This may include adrenal tumors (benign or malignant), Cushing's syndrome, Conn's syndrome (primary hyperaldosteronism), pheochromocytoma, or other adrenal disorders.Medical necessity should be clearly documented in the medical record.

The surgeon performs the adrenalectomy, including making the appropriate incision, exploring the abdomen, performing biopsies if necessary, removing the adrenal gland(s) or tumor, and closing the incision.

IMPORTANT:(Do not report 60540, 60545 in conjunction with 50323) (For bilateral procedure, report 60540 with modifier 50) (For excision of remote or disseminated pheochromocytoma, see 49203-49205) (For laparoscopic approach, use 60650)

In simple words: This procedure involves surgery on the adrenal glands, small organs located above the kidneys. It covers removing all or part of one or both glands, exploring the glands, and taking a tissue sample.The surgery can be done through different incisions in the abdomen or back.It also includes removing a nearby tumor if present.

This code describes a surgical procedure involving the adrenal glands, which are located above the kidneys. It includes partial or complete removal of one or both adrenal glands, exploration of the adrenal gland(s), and biopsy if performed. The procedure can be done through a transabdominal (across the abdomen), lumbar (vertical incision from armpit to pelvis), or dorsal (curved flank incision over a rib) approach. It also includes excision of an adjacent retroperitoneal tumor (a tumor behind the abdominal lining).

Example 1: A patient with an adrenal tumor undergoes a transabdominal adrenalectomy with excision of the tumor., A patient with Cushing's syndrome (caused by an overactive adrenal gland) undergoes a partial adrenalectomy via a lumbar approach., A patient with an incidentally discovered adrenal mass undergoes exploration of the adrenal gland with biopsy via a dorsal approach.

Documentation should include the operative report detailing the surgical approach, the size and location of any tumors or masses, whether a biopsy was performed, and any complications encountered. The medical record should also contain documentation supporting the medical necessity of the procedure, such as imaging studies, lab results, and consultation notes.

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