Otolaryngology Coding Alert

Unless you grasp neck and ear anatomy, you could cut $336 in facial tissue transfer (14040) reimbursement by instead reporting branchial cleft cyst excision (42810).

See if your vocab is up to par by examining the following operative report.

Procedure: Excision of left preauricular first branchial cleft sinus tract in a previously operated field.

Pre-/postoperative diagnosis(es): Recurrent left preauricular first branchial cleft sinus tract.

Note: This procedure qualifies for modifier 22 because it is a revision surgery in a previously operated field.

Specimens sent to lab: Overlying skin plus the deep sinus tract.

Indications for surgery: Recurrent left preauricular sinus tract.

Findings in surgery: Scarred preauricular areas from previous excision with no cutaneous fistula and no discernible sinus tract.

Procedure: - An incision was made with the #11 scalpel blade around the area that the parents had stated most recently drained. This area was over the tragal cartilage region. A portion of the tragal cartilage was transected as the deep plane of the excision. Then, dissection was carried inferiorly and superiorly plus anteriorly to remove this portion of the pretragal scar and deep tissue. The depth of the dissection was the parotid gland. It was apparent that there was a large amount of scar tissue at the anterior excision site, and this was felt to also contain branchial cleft sinus tissue. Therefore, further excision of the scar was performed with the #11 and #15 scalpels, and a large portion of tissue removed down to and including a portion of the superficial aspect of the parotid gland. ...

After removal of the specimen, a significant defect was present in the preauricular region. The closure of this area required undermining the facial skin inferior to the oracle and then anteriorly approximately one-third to 40 percent of the way to the corner of the mouth and lateral canthus of the eye. The tissue was then advanced and portion of the tissue rotated to allow a closure in a parotidectomy or fascial fashion in the preauricular area with a T-segment going anteriorly at the level of the tragus. Plicating 3-0 chromic sutures were used to reduce the space made vacant by excision of the deep tissue. This closure of the deep space was made possible by advancing the adipose tissue posteriorly and superiorly. Again, this tissue was held in place with 3-0 chromic suture.

Identifying whether the cyst excision was in the neck or ear region avoids using a code from an incorrect CPT anatomy section.

Make sure you don't lump branchial and preauricular cysts. "Each is from a different embryological source," explains John Fink, MD, an otolaryngologist at Dearborn Ear, Nose, and Throat in Michigan.

For branchial cysts, you-ll be in the neck section. "Branchial cleft cysts are congenital cysts that arise in the lateral aspect of the neck when the second branchial cleft fails to close during embryonic development," according to "Pictures and Imaging of Branchial Cleft Cysts" by Bechara Y. Ghorayeb, MD, with Otolaryngology Houston. "At about the fourth week of embryonic life, four branchial (or pharyngeal) clefts develop between five ridges known as the branchial (or pharyngeal) arches. These arches and clefts contribute to the formation of various structures of the head and neck."

"I use 42810 (Excision branchial cleft cyst or vestige, confined to skin and subcutaneous cyst) when the branchial cyst is superficial," explains Janet Kidneigh, at The Children's Hospital in Aurora, Colo. If the provider dissects all the way to the tongue base or tonsillar pillars, report 42815 (Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx).

Preauricular cysts come from the six hillocks that form the external ear, Fink explains.

Result: You can't use 42810 or 42815 in the above operative report. "This is a preauricular sinus track and 42815 is in the neck around the tonsil area," explains Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.

"Pre-auricular cysts connect to the outside with a sinus tract that opens into a pit, just anterior to the root of the helix," Ghorayeb notes. "Cystic lesions near or around the external auditory canal are believed to represent first branchial cleft duplication anomalies." Tracts arising from or paralleling the external auditory canal can lead to a cystic cavity, which will become recurrently infected and often drain in or near the ear.

CPT could throw you another curve with 60281 (Excision of thyroglossal duct cyst or sinus; recurrent) unless you can connect a third type of cyst with the corresponding anatomy. The operative report's cyst "is not a thyroglossal duct cyst [TDC]," points out Julie Keene, CPC, at University ENT Specialists Inc. in Cincinnati.

Ghorayeb explains, "Thyroglossal duct cysts are remnants of the embryonic thyroglossal duct that may occur anywhere from the base of the tongue to the thyroid gland. The majority, however, are found at the level of the thyrohyoid membrane, under the deep cervical fascia. They are midline or just off the midline, and move up and down upon swallowing. Occasionally, a sinus tract is present in the midline without a visible cyst. This midline sinus tract represents the remnant of the thyroglossal duct. It may open into the region of the hyoid or lower above the sternal notch."

Key words: "I look for the hyoid dissection before I use 60281," Kidneigh says. "The physician may also call this a Sistrunk procedure. Still, I make sure that hyoid dissection occurs."