Otolaryngology Coding Alert

Question: The physician performed surgery to remove a titanium screw from the floor of a patient's mouth. The patient had previous genioglossus surgery in which a screw had become extruded from the medial aspect of the symphysis. Should I go unlisted or use another CPT^® code to document this procedure?

Montana Subscriber

Answer: Before going with the unlisted code 41599 (Unlisted procedure, tongue, floor of mouth), you should explore all your options for a more specific CPT^® code that matches the procedure's description. Some coders may consider code 40804 (Removal of embedded foreign body, vestibule of mouth; simple) or 40805 (... complicated); however, these codes do not align with the procedure performed. The vestibule of the mouth is defined as a thin space between the teeth and gums, and the lips and cheeks; it does not include the teeth. Obviously, based on this definition, these procedure codes do not document removal of an object from the floor of the mouth.

However, there is a code that more accurately matches the description of the procedure above:

• 20680 - Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)

While this code isn't specific to the floor of the mouth, it does pertain to any instances of removal of a musculoskeletal fixation device. The only underlying question has to do with whether or not the lodged screw can be considered deep versus superficial. As long as thephysician documents that he or she had to dissect fascia and/or muscle tissue in order to reach the screw, you may consider the screw to be a deep, rather than superficial, implant.