General Surgery Coding Alert

Mistaken identity could sacrifice pay.

Surgeons may perform tongue biopsies, lesion excisions, or resections for patients with a range of conditions, including lingual cancers.

Let our experts guide you through the terminology, code choices, and coding rules to make sure you code every case correctly and garner the pay your surgeon deserves.

Master the Terminology

Your surgeon’s op note for a tongue case might include lots of terms — some familiar and some unfamiliar. Study this glossary to help you translate the op note to the CPT^® terms that guide your code selection.

• Oral tongue – refers to the anterior (front) two-thirds of the tongue
• Base of the tongue – refers to the posterior (back) one-third of the tongue, which is part of the oropharynx (throat), not the mouth
• Glossectomy – refers to removal of all or part of the tongue, usually due to cancer or precancerous changes. Glossectomy comes in the following forms:
  • Partial – the surgeon removes part of the tongue
  • Hemi – the surgeon removes one side of the tongue
  • Total – the surgeon removes the entire tongue
• Biopsy – removal of a sample of tissue or cells for diagnostic purposes, not as a treatment to remove all diseased tissue
• Excision – removal of an entire area of diseased tissue, such as a lesion, as a surgical treatment for a condition
• Resection – similar to excision, but involves removing all or part of an organ or body part

Know the Tongue Code Families

When the surgeon performs a tongue biopsy, CPT^® provides these two code choices:

• 41100 (Biopsy of tongue; anterior two-thirds)
• 41105 (...posterior one-third).

For a tongue lesion excision, you’ll need to know the site and whether the procedure involves closure to correctly indicate one of the following codes:

• 41110 (Excision of lesion of tongue without closure)
• 41112 (Excision of lesion of tongue with closure; anterior two-thirds)
• 41113 (... posterior one-third)
• 41114 (… with local tongue flap)

Coding tip: If your surgeon excises a tongue lesion without closing the wound site, you should report 41110 regardless of the location on the tongue. Use 41114 if the surgeon uses flap closure, but use 41112 or 41113 for primary closure, which is more common.

Resection: The op note for a tongue resection will describe a more extensive procedure than a lesion excision. “Look for the following information in the note to identify the service as a resection and to help you choose the appropriate procedure code,” advises Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, revenue cycle director for Clinical Health Network for Transformation in Houston, Texas:

• The extent of tongue structure removed
• Whether the procedure extended to a neck dissection
• Whether the surgeon removed part of the floor of the mouth
• Whether the resection involved the mandible

CPT^® provides eight glossectomy codes for you to select based on the preceding information from the op note:

• 41120 (Glossectomy; less than one-half tongue)
• 41130 (…hemiglossectomy)
• 41135 (…partial, with unilateral radical neck dissection)
• 41140 (…complete or total, with or without tracheostomy, without radical neck dissection)
• 41145 (…complete or total, with or without tracheostomy, with unilateral radical neck dissection)
• 41150 (…composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection)
• 41153 (…composite procedure with resection floor of mouth, with suprahyoid neck dissection)
• 41155 (…composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type))

Coding tip: You may separately report any documented reconstruction, such grafts, in addition to the resection code.

Try Your Hand at This Tongue Case

Look at the following note and see if you can assign the correct procedure and diagnosis codes.

Procedure: A 42-year-old male established patient complains of white patches on the back of his tongue that are slightly painful. The patient responds to questions that he is currently a smoker, but does not use alcohol. Upon examination, the surgeon notes the presence of a 2 cm white lesion and a 2.4 cm white lesion on the lateral border of the posterior third of the tongue with normal-looking surrounding tissue. The lesions have a folded appearance, with the most posterior 2.4 cm lesion bearing a slightly ulcerated surface. After numbing the area, the surgeon uses a scalpel for sharp removal of an 8 mm portion of the ulcerated lesion, closing the site with two sutures. The surgeon sends the sample to pathology for histological studies.

Code: The correct procedure code for the case is 41105, because the note describes a biopsy of a lesion on the posterior tongue region. This choice is clear from the op note even if the surgeon didn’t use the term, “biopsy.” “The note clearly describes removal of a portion of a larger lesion, which makes this a biopsy,” says Brame-Joy. “Don’t let the mention of closure fool you into choosing a lesion excision code,” she continues.

Diagnosis: The pathology report indicates findings of hyperkeratotic mucosa, papillary acanthosis appearing as koilocyte-like cells, intranuclear inclusions, and Epstein Barr virus-encoded RNA (EBER) in epithelial cells based on a chromogenic in situ hybridization (CISH) RNA probe stain. The pathologist diagnoses the tongue specimen as hairy leukoplakia.

Basing the diagnosis on the pathology report, the correct diagnosis code is K13.3 (Hairy leukoplakia). This code “is a direct link when using the ICD-10-CM Index and is verified the Tabular List” of the ICD-10-CM code book, says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado.

Use additional: ICD-10-CM instructs you to “use additional code” for K13.- codes. In this case, you should additionally report Z72.0 (Tobacco use).