Otolaryngology Coding Alert

Here’s your quick refresher on what each procedure involves. 

If your otolaryngologist documents that he performed a neck dissection, do you understand what happened? If not, keep reading for the rundown on the different types of dissections and what each involves. 

Foundation: Seeing notes about a neck dissection means that your surgeon removed some (or all) of the patient’s lymph nodes in the neck, plus possibly removed some other structures. A “neck dissection” is another way of saying that a “lymphadenectomy” was performed. CPT® includes three procedure codes for neck dissection: 

• 38720 – Cervical lymphadenectomy (complete) 
• 38724 – Cervical lymphadenectomy (modified radical neck dissection) (also referred to as a “MRND”)
  
• 38700 – Suprahyoid lymphadenectomy.

Understand What Each Code Includes

A complete, or radical, neck dissection (38720) involves removal of all lymph nodes from levels 1 through 5 of the neck along with removal of the sternocleidomastoid muscle, the spinal accessory nerve, and the jugular vein. These procedures are known as “radical” because the surgeon removes many structures. 

A modified radical neck dissection (38724) is a little more difficult, but also involves removal of all the lymph nodes from levels 1 through 5. The difference between the modified and radical/complete dissection is that the modified spares at least one (or more) of the other structures that are removed during a radical dissection. The surgeon spares the sternocleidomastoid muscle, spinal accessory nerve, or internal jugular vein (or possibly spares more than one of the structures). “This is the most common neck dissection performed today, now that sparing techniques have been perfected and taught,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

During the third code’s procedure, 38700, the surgeon removes only the patient’s lymph nodes above the hyoid or limited regions of the neck. 

Another term: In some instances, your otolaryngologist might document that he performed a selective or functional neck dissection. The American Medical Association (AMA) recommends reporting 38700 for the procedure. However, the AMA states that a “Selective neck dissection can include levels I-III, levels II-IV, level VI.  Levels I-III do fall under the description of 38700, but the other possible iterations that may fall under a “Selective neck dissection” do not apply to 38700.  So the American Academy of Otolaryngology advises submitting 38724 with modifier 52 (Reduced services). Check with the payer in question to verify which way they want you to file for the service. 

Check for Unilateral or Bilateral Service 

Any of the neck dissection procedures can be completed as either unilateral or bilateral. CPT® guidelines state that you should report modifier 50 (Bilateral procedure) with the applicable surgical code when reporting a bilateral procedure. 

Caution: Some payers might not accept modifier 50 in conjunction with these codes. If not, you’ll need to report the procedure code on two separate lines and append modifier 59 (Distinct procedural service) to the second code to document it as a separate side. 

“It is not incorrect if you would like to add a second modifier to the 59 modifier, adding a LT and a RT to each charge line respectively, after the 59 modifier,” Cobuzzi says. “This adds clarity and avoids claims of duplication in your charges.”

Beware of Potential Bundles 

Surgeons often perform a total laryngectomy or total glossectomy in conjunction with a modified radical neck dissection for cancer patients in order to make sure that they remove all of the diseased nodes.   

The bundled codes for these services are 31365 (Laryngectomy; total, with radical neck dissection) and 41145 (Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection). Note that the codes are old and do not recognize that modified radical neck dissections are performed most often as opposed to radical neck dissections. They therefore do not correctly represent a laryngectomy with a modified neck dissection nor do they represent a glossectomy with a modified neck dissection.  

But Correct Coding Initiative (CCI) edits bundle 31360 (Laryngectomy; total, without radical neck dissection) and 41140 (Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection) with a modified neck dissection, 38724.  The edits direct you to report the laryngectomy with the radical neck dissection or glossectomy with radical neck dissection. 

Take note: When the surgeon performs a radical neck dissection on the same side as the laryngectomy or glossectomy, you do not have sufficient reason or documentation to support the use of a modifier (59 or XS for Medicare Part B) to support billing both a laryngectomy or glossectomy and the modified radical neck dissection (38724). “Your only choice is to bill the lower RVU bundled code (31365 or 41145) that describes the less difficult service (radical neck dissection) that was not performed, where a more difficult service (ie: the modified radical neck dissection) was performed,” Cobuzzi says.

If your surgeon performs a laryngectomy with a bilateral modified neck dissection or a glossectomy with a bilateral neck dissection, you can bill for the second side’s modified neck dissection with a 59 modifier (or XS for Medicare Part B) because it is located on the contralateral side from the laryngectomy or glossectomy. The billing for the laryngectomy with bilateral modified neck dissections would look like:

• Laryngectomy

              o 31365-RT
              o 38724-59-LT

• Glossectomy for Medicare Part B patient:

              o 41145-LT
              o 38724-XS-RT