Letter to the Editor: New Current Procedural Terminology Codes for Radiofrequency Ablation of Thyroid Nodules Will Negatively Affect American Patients According to the Executive Council of the North American Society for Interventional Thyroidology

Dear Editor:

In November 2024, the Center for Medicare and Medicaid Services (CMS) in the United States announced the creation of Current Procedural Terminology (CPT) codes (60660 and 60661) for radiofrequency ablation (RFA) of thyroid nodules and assigned relative value units (RVUs) of 5.75 and 4.25 for initial and additional contralateral nodules, respectively. ¹ Even though the CPT codes were much anticipated by the thyroid community, we believe the proposed codes will result in increased costs, worse patient outcomes, and reduced reimbursement to the point that it is impossible for some providers to provide treatment. The North American Society for Interventional Thyroidology (NASIT) and other organizations with members who perform thyroid RFA have advocated unsuccessfully for modifications to the proposed changes.

By assigning 5.75 RVUs for thyroid nodule RFA, CMS has ensured that RFA must be completed in a setting where facility fees can be added to the professional fee in order to cover costs. As most RFA procedures performed by our members are currently completed in procedure rooms or outpatient clinics, this will cause an immediate shift toward more expensive hospital-based facilities. A similar change occurred when CMS reduced reimbursement for fine needle aspiration biopsies (FNA) of thyroid nodules in 2017. The result, which we now anticipate will also occur with RFA, was increased costs to CMS and a decrease in convenience for patients. ²

Worse patient outcomes are incentivized because a new add-on code will increase total RVUs to 10 when a contralateral nodule is treated. It is the position of NASIT, the American Thyroid Association (ATA), and other societies with position statements on this topic that contralateral nodules should rarely—if ever—be treated simultaneously. ³ Patient safety is the primary reason for this caution, as airway swelling and delayed injury to the recurrent laryngeal nerve have both been reported. Treating bilateral nodules may cause worse patient outcomes.

Finally, by assigning modest RVUs to these procedures, CMS implies that risks and time allocated to thyroid RFA should be modest, thereby indirectly discouraging practitioners from thoroughly and completely treating larger, more time-consuming nodules.

We predict that the result of these changes will be that most patients will undergo RFA of their thyroid nodules in settings that incur higher patient costs, more patients will undergo treatment of bilateral nodules, and smaller, asymptomatic, nodules will be preferentially treated instead of large nodules that are symptomatic. Additionally, repeat treatments could become the norm if larger nodules are incompletely treated due to time constraints enforced by low reimbursement.

RFA has a robust body of literature showing that it is both safe and effective for patients with benign symptomatic thyroid nodules when completed thoughtfully and completely by experienced physicians. It is cost effective relative to surgery. Creating a CPT code is a necessary step toward improving access for all patients. Unfortunately, the assignment of RVUs as currently recommended creates misguided financial incentives and encourages worse patient outcomes and increased costs.

Sincerely—

The Executive Board of the North American Society for Interventional Thyroidology.