Otolaryngology Coding Alert

Question: I recently performed surgery on a patient with an arteriovenous malformation (AVM) overlying a chronically infected submandibular gland with stone. How would I code this procedure? The patient underwent excision of ateriovenous malformation, as well as excision of left submandibular gland with stone.

Ronald Iannacone
Ear, Nose, Throat, Head & Neck Associates, P.A., Mannaquan, N.J.

Answer: The AVM is not a surrounding tumor, it is an artery/vein malformation. The otolaryngologist performs the planned surgery (42440, excision of submandibular [submaxillary] gland) on the submandibular gland and in the process of freeing all the adhesions and vessels, encounters this malformation along the way. This is an unexpected anatomical structure in the area, but it does not qualify as a distinct procedure, says Cheryl Odquist, CPC, a coding and reimbursement specialist in San Diego, Calif.

It would probably be appropriate to bill for the submandibular gland excision by attaching a -22 modifier (unusual procedural service) to the 42440, Odquist says. Remember to increase the fee and include a cover letter with the claim and a copy of the operative note that explains the increased complexity and justification for additional payment. In all probability, when first processed, the -22 will be ignored and will have to be appealed for the appropriate reimbursement.