Inpatient Facility Coding & Compliance Alert

Question: The patient is a 54-year-old female who presents with right-sided face pain. ENT exam shows a 1 mm stone on the right buccal region of the mucosa. The ED physician documented a diagnosis of sialolithiasis with the following procedure note: 

Location: inner right cheek.

Confirmed: Patient, procedure, side, and site correct, Time-out taken prior to procedure.

Procedure: removal of stone from the right mucous membrane, scalpel # 15 used to incise the bulging right buccal mucosa with the stone tip in view.

Procedural sedation: None.

Patient tolerated: Well.

Complications: None.

Performed by: EDMD.

Total time: 7 minutes.

Would this be reported as a foreign body removal with CPT^® code 40804 (Removal of embedded foreign body, vestibule of mouth; simple) or 41805 (Removal of embedded foreign body from dentoalveolar structures; soft tissues); or a completely different code?

West Virginia Subscriber

Answer: The correct CPT^® code would be 42330 (Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral).

Explanation: With the diagnosis of sialolithiasis, the stone that was removed is not a rock or pebble type stone but rather a calculus that forms in an organ or duct of the body. Think kidney stone, not gravel. Sialolithiasis refers to the formation of stones in the salivary glands which can obstruct the salivary ducts. A variety of treatments are available; hydration, NSAIDs , foods to increase salivation to promote spontaneous expulsion of the stone; some stones may be massaged out, a specialist may cannulate the duct to remove the stone; or as in this case the physician may make a small incision near the stone to remove it.