Otolaryngology Coding Alert

Navigate through a variety of concepts to further your coding acumen.

There’s often no better way to enhance your skills as a coding professional than to work through a challenging specialty-specific example. While otolaryngology coders tend to favor coding those high-frequency procedures involving the ears, nose, and throat, there are other surgeries involving each respective anatomic site that require a little more focus to get right.

Today, you’re going to make your way through a tricky, multifaceted report involving a suprahyoid lymph node excision, a modified radical neck dissection (MRND), and a buccal mucosal lesion resection.

Tag along for a breakdown of the coding mechanics and a few integral tips to get you to the correct set of codes within your CPT^® book.

Avoid Pitfalls While Navigating the CPT^® Index

Example: The surgeon performs a bilateral suprahyoid lymph node excision with a modified radical neck dissection and a buccal mucosal lesion resection.

The coding of each of these three respective procedures is relatively straightforward so long as you’re fluent with all the involved anatomy and medical terminology. After reporting the correct code set, your only additional considerations are modifiers and bundling via National Correct Coding Initiative (NCCI) edits.

First, you’ll want to address the bilateral suprahyoid lymph node excision (also known as a lymphadenectomy). Excision ? Lymphatic System leads you to “See Lymphadenectomy.” You can then reach code 38700 (Suprahyoid lymphadenectomy) with modifier 50 (Bilateral Procedure) via either of the two following routes:

• Lymphadenectomy ? Suprahyoid
• Lymph Nodes ? Suprahyoid ? Excision

Next, you’ve got to be careful as to how you reach code 38724 (Cervical lymphadenectomy (modified radical neck dissection)) via the CPT^® index. You’ll see that the term radical neck dissection does not include any subterms identifying an MRND. That’s why it’s important to distinguish an MRND from a RND. An MRND involves the excision of cervical lymph nodes, which is one surgical component of an RND. Since the excision of lymph nodes is also known as a lymphadenectomy, you’ll find the correct code via Lymphadenectomy ? Cervical ? 38720-38724. An alternative route is Lymph Nodes ? Cervical ? Lymphadenectomy ? Modified ? 38724.

Stay on Top of Important Anatomical Distinctions

The last piece of the coding puzzle is determining the correct code to report for a buccal mucosa resection. Again, you’ll need some proper anatomical context to reach the correct CPT^® code. The buccal mucosa involves the lining of the cheeks and the back of the lips. A resection, or excision, of the buccal mucosa can be found by searching for the following index term:

• Excision ? Mouth ? Lesion ? 40810-40816, 41116

Note: Excision ? Mouth ? Mucosa or Excision ? Mucosa ? Vestibule of Mouth will lead you to code 40818 (Excision of mucosa of vestibule of mouth as donor graft). While this index pathway might make sense, the code you’ve landed on does not. Code 40818 will be reported when the physician harvests mucosa from an area within the vestibule of the mouth to use as a donor graft within another site of the mouth.

Instead, you’ve got to factor in the diagnostic component of the procedure. An excision of a lesion within the mouth will present you with the following range of oral mucosal excision codes to consider:

• 40810 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair)
• 40812 (… with simple repair)
• 40814 (… with complex repair)
• 40816 (… complex, with excision of underlying muscle)

So long as you’re aware that the buccal mucosa is a component of the vestibule of the mouth (CPT^® defines it as including the mucosal and submucosal tissue of the lips and cheeks), then you’ve only got to distinguish between types of repair. Assuming there is no documentation of excision of underlying muscle, you may rule out 40816. Furthermore, 41116 (Excision, lesion of floor of mouth) can be ruled out since the buccal mucosa is a part of the vestibule of the mouth.

Consider Rules on Reporting Simple, Complex Repairs

You’ll notice that there are no CPT^® guidelines that elaborate on what constitutes a simple versus complex repair. This means that you’ll have to rely on the discretion of both you and the provider based on what’s documented in the operative report. Furthermore, keep in mind that a complex removal does not necessarily constitute a complex repair. However, there are a few ways to determine whether the operative report justifies the jump from simple to complex repair.

First, if the physician documents circumstances that result in a heightened degree of difficulty in achieving the repair, you may report code 40814. This also includes documentation of a “layered” closure, which is typically performed following an excision that borders on the level of complex. During a layered closure, the surgeon will use sutures on both the lining and underlying connective tissue in order to merge them together to prevent infection.