Otolaryngology Coding Alert

Question: How would you code for biopsy of lower lip minor salivary glands?

New York Subscriber

Answer: The answer depends on whether the otolaryngologist performed the biopsy with a needle or via an incision.

If the op note mentions a needle aspiration, look at 42400 (Biopsy of salivary gland; needle). For this procedure, the otolaryngologist inserts a large, hollow bore percutaneous needle (for instance, Tru-Cutor Menghini) into the salivary gland and obtains small tissue fragments for the purpose of a biopsy.

On the other hand, if the otolaryngologist made an incision to attain the biopsy, look at 42405 (Biopsy of salivary gland; incisional). For this procedure, the physician makes an incision over the salivary gland and takes out some tissue (six to ten pieces) from the gland to submit it for examination. Then the incision is closed.