General Surgery Coding Alert

Question: Our surgeon removed two stones from the parotid gland. He inserted a sialoendoscope and used a basket to retrieve the first stone. He was unable to remove the second, larger stone endoscopically, so he made an incision and performed a sialolithotomy. How should we code this?

Georgia Subscriber

Answer: You should report two separate procedures for the different approach and removal of two distinct stones.

CPT^® does not provide a code to report endoscopic stone removal from the parotid gland, so you’ll need to use an unlisted code such as 42699 (Unlisted procedure, salivary glands or ducts). Make sure to provide adequate documentation to indicate what procedure your surgeon performed and why you have chosen an unlisted code for the procedure. You should also provide details about what reimbursement you are claiming and why.

Because the surgeon removed the second stone through an incision, you should report an appropriate sialolithotomy code for the procedure, as follows:

• 42330 — Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral
• 42340 — Sialolithotomy; parotid, extraoral or complicated intraoral.

Choose from one of these two codes based on the approach used by your surgeon. For an extraoral approach, you will have to report 42340.

If your surgeon documents an intraoral approach, you may choose 42330 or 42340, depending on the complexity of the procedure. Determining the complexity should include documentation such as the depth your surgeon had to dissect to approach the stone for removal, the amount of tissue he removed, and the type of repair he performed.

For instance, if the surgeon removed significant tissue to retrieve the large stone, which required layered closure, you might select 42340 for the larger stone removal.