Otolaryngology Coding Alert

Question: My otolaryngologist performs resection of tonsillar fossa and right lateral pharynx, hemiglossectomy, tongue base resection, resection of one half of the soft palate, RT level-five neck dissection, neurolysis of cranial nerve XII, and tracheotomy. How should I code this surgery?


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Answer: Before you can code this operation, you will have to go back to the otolaryngologist or the operative report for a few more details. Here are some possible procedures you may report:

1. Lymphadenectomy: Find out if the otolaryngologist performed the lymph procedure - the RT level-five neck dissection - via a "modified" field. Check if the surgeon dissects and preserves the sternocleidomastoid (SCM) muscle, the accessory nerve or the jugular vein. If he does, you could consider reporting that piece with 38724 (Cervical lymphadenectomy [modified radical neck dissection]). If the surgeon doesn't preserve those structures, look at 38720 (Cervical lymphadenectomy [complete]) or 38700 (Suprahyoid lymphadenectomy).

2. Cranial nerve neurolysis: Whether you may bill this procedure depends on what the otolaryngologist is doing and the reason for it. Is the otolaryngologist destroying the nerve to gain access or to excise it for tumor removal? You shouldn't report the nerve destruction, if the surgeon does it to gain access. You shouldn't report  nerve destruction if the surgeon does it to gain access.

3. Tracheostomy: To determine whether you should separately bill the tracheostomy, see if the main procedure always requires a trach. If the surgeon can't perform the procedure without performing a tracheostomy, the surgery includes the tracheostomy. For instance, a laryngectomy always includes a tracheostomy.

4. Main procedure: One of several radical excision codes may apply. You should look at 42890-42894 (pharyngectomy), 41120-41155 (glossectomy), 42120 (palate or extensive lesion resection), 42842-42845 (radical tonsil, tonsillar pillars and/or retromolar trigone resection). Depending on the excision approach, the surgeon's documentation and the resected structures, you may be able to report more than one of these codes.