Otolaryngology Coding Alert

Work your way through two examples to drive the point home.

While submitting to the payer using an unlisted CPT^® code is always a last resort, working within the parameters of the CPT^® manual often leaves you no choice in the matter. In the otolaryngology world, there are a few sets of procedures which, until further notice, you’re left with no other option than to report using an unlisted code.

Some common procedures that require unlisted codes are eustachian tube balloon dilations, balloon septoplasty, and endoscopic resection of sinonasal/skull base tumors. However, there’s another surgical procedure without a proper home in the CPT^® manual that often goes overlooked — sialendoscopies.

Read further to break down exactly what this surgery entails — and how to properly code for it — using a few helpful examples.

Begin by Outlining a few Important Key Points

In a previous issue, you went over various surgical cases involving the salivary glands in an article titled Wrangle in This Set of Tricky Salivary Duct Procedure. You’ll often find that a physician will perform a sialendoscopy procedure alongside some of those covered in the aforementioned article. But before diving into a few examples, get the full scoop on when, where, and why a provider will opt to perform a sialendoscopy.

A sialendoscopy, simply put, is an endoscopic evaluation of the salivary glands. The physician may opt for this procedure for a variety of reasons. Most notably, you’ll typically see a sialendoscopy performed to further elaborate on a pathological area of the salivary glands. This may include visualization of a site within the salivary glands plagued by infection, inflammation, salivary stones, or even a neoplasm.

Depending on the pathology, the physician may opt for a variety of courses of action. For example, sialendoscopy resulting in a neoplasm may require a biopsy. A sialendoscopy that exposes an area of sialadenitis may require a steroid injection. Lastly, the provider may even opt to remove a salivary stone using a sialendoscope in some circumstances.

Identify Correct Unlisted Code, Comparison Code

Understanding the context as to when the surgeon performs a sialendoscopy is only half the battle, though. As you may have already learned through experience, getting the coding mechanics right is problematic due to the fact that there is no existing code within the CPT^® manual to report a sialendoscopy. Instead, you’ve got to report sialendoscopy procedures using unlisted code 42699 (Unlisted procedure, salivary glands or ducts).

When submitting an unlisted code to a payer, your first point of business is to determine the most appropriate comparison code. Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey, advises that you use 42335 (Sialolithotomy; submandibular (submaxillary), complicated, intraoral) when the physician performs the sialendoscopy to remove a stone, but you shouldn’t stop there. “In determining relative value, you want to equate 42699 to a percentage of excess of 42335, as determined by the surgeon. For example, the surgeon may feel that they performed 135 percent of the work included in code 42335. On another hand, if the stone was easier to remove because of its position and small size, the surgeon may feel that the unlisted code is equal to 85 percent of 42335,” explains Cobuzzi.

Now, have a look at the following two examples to make sure you’re well-equipped to code surgical reports that include sialendoscopy procedures.

Work Through 2 Relevant Examples

Example: The surgeon makes an unsuccessful attempt at cannulating and dilating the right Wharton’s Duct. The surgeon moves to the left Wharton’s duct where the duct is probed, cannulated, and dilated. The surgeon introduces a sialendoscope for complete visualization of the duct. Finally, the surgeon injects 3 ccs of Kenalog 10 and withdraws the sialendoscope.

Here, you’ve got to consider coding for both the right and left Wharton’s duct. For the right Wharton’s duct, you may code for the terminated dilation procedure using 42650 (Dilation salivary duct) with modifier 53 (Reduced Services).

Coder’s note: “You should reserve modifier 53 (Discontinued Procedure) for scenarios in which the physician terminates the procedure due to safety concerns for the patient, not discontinued procedures when they are simply unsuccessful. So long as part of the dilation works, but the duct is not successfully dilated, you should use modifier 52 and document how much of the procedure was accomplished in Box 19,” advises Cobuzzi.

Keep in mind that you do not have enough documentation to support coding this terminated dilation with 42660 (Dilation and catheterization of salivary duct, with or without injection). Cannulation is not the same as catheterization, and unless the surgeon specifically documents catheterization prior to dilation, you may not report 42660.

You’ll then move on to the coding breakdown for the left Wharton’s duct. First, you’ve got a cannulation and dilation, which you should report with 42650. Next, you’re going to repot 42699 for the sialendoscopic injection. Lastly, you may report J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) for the injection of Kenalog 10 when the physician performs the procedure in an office.

Keep in mind: The drug will be charged by the facility if the procedure is performed in an operating room (OR) or in an outpatient facility. There are no endoscopic injection CPT^® codes in the digestive section, but the claim can equate the unlisted code to 31570 (Laryngoscopy, direct, with injection into vocal cord(s), therapeutic) in Box 19 of the claim form for pricing. The provider may want to indicate a percentage of 31570 that a sialendoscopic injection represents based on their clinical judgement also in Box 19.

Example: Sialendoscopy reveals lodged stone in the left submandibular gland. The physician removes the stone using sialendoscope.

If the documentation supports dilation and cannulation or catheterization in order to introduce the sialendoscope, you’ll want to begin by incorporating the appropriate CPT^® codes for that preliminary portion of the surgery. The subsequent removal of the stone using a sialendoscope warrants the reporting of unlisted code 42699 with pricing in Box 19 as described above.

It’s up to the discretion of your provider as to whether you choose to fill in Box 19 with comparison code 42335 or 42330 (Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral). If the operative report details an inherently simple procedure, then 42330 may be a more suitable comparative option.