Otolaryngology Coding Alert

CPT 2002 distinguishes more than a dozen glossectomy-related codes from one another, based on the location and size of the portion of the tongue that was removed and whether other procedures were performed during the glossectomy.
 
Glossectomy-related procedures are performed most often on patients with lingual cancers, such as a squamous cell carcinoma of the oral tongue, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's Editorial Panel and Executive Committee.
 
Note: The "oral tongue" includes the anterior two-thirds of the tongue; the "base of the tongue" includes the posterior one-third of the tongue.
 
Eisenberg breaks glossectomy-related codes into two groups, the first group covering diagnostic procedures (such as biopsies and lesion excisions) and the second group covering glossectomy procedures themselves.

Biopsy Codes. The portion of the tongue on which the procedure is performed distinguishes the biopsy codes from one another:

 

41100 biopsy of tongue; anterior two-thirds
 

41105 ... posterior one-third.

Lesion Excision Codes. The portion of the tongue on which the procedure is performed, as well as the need for closure of the wound, distinguishes the four lesion excision codes from one another:

41110 excision of lesion of tongue without closure

41112 excision of lesion of tongue with closure; anterior two-thirds

41113 ... posterior one-third

CPT 41115 excision of lingual frenum (frenectomy).

When a significant portion of the tongue is removed, the procedure should be reported using one of eight glossectomy codes. These codes vary according to 1) the amount of tongue that is removed, 2) whether a neck dissection was performed, 3) whether a resection of the floor of the mouth was also performed and 4) whether the mandible was resected.
 
Glossectomy procedure codes include:

41120 glossectomy; less than one-half tongue

41130 hemiglossectomy

41135 partial, with unilateral radical neck dissection

41140 complete or total, with or without tracheostomy, without radical neck dissection

41145 complete or total, with or without tracheostomy, with unilateral radical neck dissection

41150 composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection

41153 composite procedure with resection floor of mouth, with suprahyoid neck dissection

41155 composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (commando type).

Bilateral Radical Neck Dissections. Codes 41135 and 41145 make specific reference to "unilateral" neck dissections. Sometimes, however, the otolaryngologist will perform a bilateral neck dissection or lymphadenectomy. This procedure may be reported separately using 38720 (cervical lymphadenectomy [complete]), says Andy Borden, CPC, CCS-P, CMA, reimbursement manager for the department of otolaryngology at the Medical College of Wisconsin in Milwaukee. However, he notes that "because the glossectomy code already includes a radical neck dissection, modifier -59 (distinct procedural service) should be appended to 38720 to indicate that it was performed on a separate site."
 
Modified Radical Neck Dissections. Codes 41135 and 41145 cover "radical" neck dissection, a procedure that sacrifices the spinal accessory nerve, jugular vein and sternocleidomastoid muscles so the malignant lymphatic chain may be removed. Otolaryngologists prefer to perform "modified radical" neck dissection whenever possible, however, so function of the spinal accessory nerve, jugular vein and sternocleidomastoid muscles is not jeopardized. Modified radical neck dissection is more complex than radical dissection and should not be reported using 41135 and 41145. Instead, the appropriate glossectomy code without radical neck dissection should be reported with 38724 (cervical lymphadenectomy [modified radical neck dissection]). Modifier -59 may be required here as well, Borden says.
 
For example, a patient with a painful left tongue lesion for the past four months is found to have a 3.5-cm ulcerated lesion of the left lateral tongue and a 2.5-cm firm mass in the right midjugular region. The tongue lesion is biopsied and found to be a squamous carcinoma. The otolaryngologist performs a partial glossectomy and a modified radical neck dissection, which Eisenberg suggests should be coded using 38724 and 41120-59.
 
Note: Modifier -59 is appended to 41120 rather than 38724 because it is the lesser-valued procedure.
 
"You shouldn't have to put the modifier on in such cases, because the glossectomy code does not include neck dissection. But because 41135 and 41145 include radical neck dissection, some carriers may want to recode the glossectomy with the dissection into these codes. You must indicate to the carrier that the modified radical dissection and the glossectomy are distinct procedures, and using modifier -59 helps you do that," Eisenberg says.
 
Endoscopy and Glossectomy. Carriers may bundle esophagoscopy, laryngoscopy, bronchoscopy or other endoscopy procedures with some or all glossectomy procedures. Even though there are no edits in the Correct Coding Initiative (CCI), carriers may still deny the use of any scope during these procedures as inclusive. The scope may be paid separately, however, if it is used to determine whether cancer has spread to another site that is difficult to access (such as the esophagus or the hypopharynx) or to diagnose the cancer (following which the glossectomy is immediately performed). It is not necessary to append modifier -59 to the scope procedure to indicate it was separate from the glossectomy, Borden says, as long as the scope is not bundled with the glossectomy.
 
"Usually, there is no reason for a scope code to be bundled with an open code, so there's no reason to use modifier -59, which is overutilized anyway," he says. "Modifier -59 should be used when two codes are bundled in the CCI and when, in a particular situation, there is a good reason for separate payment."
 
Note: Some endoscopy codes are bundled with certain glossectomy codes in the CCI. In such cases, modifier -59 should be used. Similarly, if a commercial carrier you are dealing with bundles a scope and glossectomy, modifier -59 should be appended to the scope when the claim is resubmitted or appealed.
 
To bill successfully for the scope, you should link a separate diagnosis (the secondary cancer, if the cancer has spread to another site, or the diagnosis that prompted the endoscopy, if the scope diagnoses the cancer) to the appropriate scope code and support the link with clear and accurate documentation.