Otolaryngology Coding Alert

"Neck dissections are difficult to code because they often are associated with a primary procedure to remove malignancy elsewhere. In some cases, these primary procedures already include radical neck dissections (RND). With other procedures, RNDs are not included and may be billed separately.

There are two main types of neck dissections radical and modified radical and different coding guidelines apply to each. When a neck dissection is performed on both sides during the same session as a primary procedure (such as laryngectomy, glossectomy, or parotidectomy), coders may need to use modifiers to indicate to the carrier that the dissection is not bundled with the primary procedure and should be paid separately.

Neck dissections are performed when malignancy is detected in the lymph nodes of the neck and associated areas. The malignancy may be primary (originating in the lymphatic system) or more often secondary (resulting from a primary malignancy elsewhere).

How to Code Lymphadenectomies

Neck dissections also are referred to as cervical lymphadenectomies. These procedures, when they are performed on their own, involve removal of the lymph node chain from the neck and are coded as follows:

38720 cervical lymphadenectomy (complete)
38724 cervical lymphadenectomy (modified radical neck dissection)

Code 38720 is used when a radical neck dissection is performed. In this procedure, lymphatic tissue, the jugular vein, the spinal accessory nerve and the sternocleidomastoid muscles are sacrificed to remove the cancerous lymphatic chain.

A radical neck dissection is performed when necessary, but because it is associated with high morbidity, otolaryngologists perform modified radical neck dissections whenever possible. In this procedure, the lymphatic chain is removed but the spinal accessory nerve, jugular vein and sternocleidomastoid muscles are preserved. Because this procedure is more meticulous, and hence more complex, it is reimbursed at a higher rate (38720 is assigned 30.18 relative value units [RVUs], whereas 38724 has 31.05 RVUs).

Note: Suprahyoid lymphadenectomy (38700), which is performed to remove lesions near the floor of the mouth, is included in both 38720 and 38724 and should not be billed separately if performed during the same session.

Clarity Lies in the Operative Report

To code neck dissections and their associated primary procedures correctly, coders need to be able to distinguish between a radical neck dissection and a modified radical neck dissection, says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an otolaryngology coding consultant in New Orleans and past-president of the Society of Otorhinolaryngology and Head-Neck Nurses.

The key is to read the operative report, says Hickey. The otolaryngologist may describe the procedure as a radical neck dissection when, in fact, a modified radical was performed, she warns. By understanding how the two procedures differ and reading the operative report, the coder should be able to choose the correct coding configuration for the procedure.

Radical and modified radical neck dissections can be billed separately in the following situations:

1. When they are performed on their own. For example, if the radical neck dissection was performed at a different time (196.0, secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck).

2. When they are performed with another procedure that does not include neck dissections in the description, such as resection of the pharyngeal wall (e.g., 42892, resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls; or 42894, resection of pharyngeal wall requiring closure with myocutaneous flap), CPT instructs physicians to bill 38720 separately. If a modified radical neck dissection was performed, 38724 should be billed instead.

3. When 38720 or 38724 are performed bilaterally (both sides of the neck) during the same session as a procedure that includes neck dissection in its description.

Check CPT Code Descriptor for Primary Procedure

Although radical and modified radical neck dissections can be billed separately in the situations listed above, more often they are performed in conjunction with a procedure to remove a primary neoplasm. Among the most common procedures linked to neck dissections are laryngectomies, glossectomies, thyroidectomies, parotidectomies and, less frequently, mastoidectomies.

Some of these procedures are described by codes that include radical neck dissection. For example, there are two codes for total laryngectomies: 31360 (laryngectomy; total, without radical neck dissection) and 31365 (laryngectomy; total, with radical neck dissection). The only difference between these codes is that 31365 includes radical neck dissection in the descriptor and 31360 does not.

Similarly, parotidectomies that include a unilateral modified neck dissection are coded 42426 (excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection), whereas those without the associated lymphadenectomy are coded either 42420 (excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve) or 42425 (excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve). Thyroidectomies with radical neck dissection are coded 60254 (thyroidectomy, total or subtotal for malignancy; with radical neck dissection), whereas total thyroidectomy without neck dissection is coded 60240 (thyroidectomy, total or complete).

The procedure with the largest number of codes associated with RNDs is the glossectomy. Of the eight codes from 41120 through 41155 that describe these tongue excisions, three include radical neck dissections (41135, glossectomy; partial, with unilateral radical neck dissection; 41145, complete or total, with or without tracheostomy, with unilateral radical neck dissection; and 41155, composite procedure with resection floor of mouth, mandibular resection and radical neck dissection [Commando type]). A fourth code, 41153 ( composite procedure with resection floor of mouth, with suprahyoid neck dissection), includes a suprahyoid dissection.

When radical neck dissections are performed on one side at the same time as any glossectomy procedures, the only code that should be billed is the one that describes the primary procedure, says Gretchen Segado, CPC, chief corporate compliance officer for Thomas Jefferson University in Philadelphia. Using a different CPT code that doesnt include radical neck dissection and billing separately for the dissection is considered unbundling and is not allowed.

Radical neck dissections are payable separately from some procedures. For example, the pharyngeal resection mentioned earlier does not include neck dissection and CPT instructs providers to list 38720 or 38724 if either is performed. RNDs also are not bundled with excisions and resections of neck tumors in the integumentary system (21555, excision, tumor, soft tissue of neck or thorax; subcutaneous) or musculoskeletal system (21556, deep subfascial, intramuscular; and 21557, radical resection of tumor [e.g., malignant neoplasm], soft tissue of neck or thorax).

Modifier -59 Identifies Bilateral RNDs

When a composite procedure such as a laryngectomy or glossectomy with radical neck dissection is performed, it is not uncommon for the patient also to have a radical lymphadenectomy on the contralateral side of the neck.
Because the code for a radical neck dissection is a unilateral code and because many of the composite procedure code descriptors specifically state that the RND included is unilateral, the second RND is a separately payable procedure. Modifier -59 (distinct procedural service), however, should be appended to the second RND to indicate it was performed at a separate site (i.e., the other side of the neck).

Modifiers -LT (left side) or -RT (right side) may also be added to let the carrier know a second RND was performed. These modifiers should only be used when a bilateral RND is performed during the same session as a procedure with a bundled RND. If the modifiers were used simply to override an edit and obtain payment, the claim likely would not survive an audit.

Note: Modifier -50 (bilateral procedure) should not be appended to the RND because only the RND on the contralateral side is separately billable. The first RND is included in the primary procedure.

For example, if a patient with laryngeal cancer has a total laryngectomy (31365) along with a bilateral modified RND, the procedures would be coded: laryngectomy, 31365; and modified RND contralateral side, 38724-59-LT (or -RT).

Note: Depending on individual preference, carriers may request modifier -59 and/or the -LT and -RT modifiers.

Check CCI for Edits

The CPT descriptors for combined procedures, such as laryngectomies or glossectomies that include RND, do not specifically refer to modified radical neck dissections. As a result, many coding specialists maintain that if a modified radical neck dissection is performed along with a primary procedure, it can be billed separately. According to CPT, the combined codes only apply to radical neck dissections. For example, if an otolaryngologist performs a laryngectomy and a unilateral modified radical neck dissection, both procedures (31365 and 38724) will be paid.

While this may be correct in theory, the national Correct Coding Initiative (CCI) bundles both 38720 and 38724 into many but not all combined procedures.

For example, the CCI lists 31365 as a comprehensive code that includes among its components both 38720 and 38724. The situation is more complicated for glossectomies, in which two of three combined procedures, 41145 and 41155, bundle 38724. the third, 41135, does not. Curiously, 41153, defined in CPT as a composite procedure with resection floor of mouth, with suprahyoid neck dissection (i.e., 38700), also bundles both 38720 and 38724.

Because of such inconsistencies in applying the edits to these procedures, otolaryngology coders need to check the CCI to determine if the primary procedure that was performed bundles 38724. If it does, only the primary procedure should be billed, Segado says.

The CCI edits have been deemed inappropriate by many clinicians and coding specialists who point out that the reason the codes are bundled in the first place is only because of the wording in the CPT descriptor of the combined procedure. These descriptors, however, state only with radical neck dissection, and do not mention the more difficult modified RND procedure.

When dealing with some private payers who do not follow the CCI, coders may want to follow the advice of some clinicians and coding specialists who recommend using modifier -59 to indicate that a different procedure or service a modified RND, as opposed to a RND has been performed.

Finally, although most Medicare carriers also will pay for 38724 if modifier -59 is attached (because modifier -59 automatically overrides CCI edits), using modifier-59 may be difficult to justify at a subsequent Health Care Financing Administration (HCFA) audit because no second RND was performed and the edit specifically bundles 38724 to the primary procedure. Until HCFA decides that these edits are inappropriate and removes them from the CCI, coders should be careful before using modifier -59 in such circumstances."