<p>This study was done to evaluate the diagnostic accuracy and concordance of ultrasonography based ACR-TIRADS scoring and Fine needle cytology grading (The Bethesda system for reporting thyroid cytopathology score 2017) using histopathology diagnosis (HPE) as a reference standard. This prospective study was conducted from 2023 to 2025 on 200 consecutive patients who underwent thyroid surgery. In terms of risk stratification for malignancy, sensitivity of the Bethesda system was 47.37%, specificity of 95.06%, positive predictive value (PPV) of 69.23%, and (NPV) negative predictive value of 88.51%. %), ACR-TIRADS show a sensitivity of 57.89%, specificity of 91.36%, PPV of 61.11%, and NPV of 90.24%. Bethesda category 2 was most commonly reported on FNAC (78%), of which, 91% were benign on final histopathology while TI-RADS score 2 was most common of which 95% was benign suggesting alignment of the two systems. A statistically significant correlation was observed between TI-RADS and Bethesda scores (p &lt; 0.0001), with maximum agreement in TI-RADS 5 and Bethesda category VI with HPE. Compared to Bethesda, TIRADS demonstrated slightly higher sensitivity but marginally lower specificity in our cohort. These findings support the synergistic use of ultrasound-based risk stratification and cytological evaluation for preoperative assessment and risk stratification. Both the systems demonstrate strength in detecting malignancy preoperatively, though moderate sensitivity is a limitation in detecting all malignant lesions preoperatively.</p>