Otolaryngology Coding Alert

Work out three coding examples to enhance your skills.

Mastering the fundamentals of ear, nose, and throat coding is one thing, but excelling at everything in between can be troublesome for all levels of coders. Surgical procedures on the salivary glands definitely qualify as one of those “in-between” services that can be especially tricky depending on the operative report.

As you’ll see in a few examples, the biggest challenge is deciding between codes that qualify for submission versus those that should be omitted and/or bundled into a more comprehensive code.

Refine your salivary gland coding skillset by putting these three examples to the test.

Discern Between Cannulation and Catheterization

In this first example, you’re looking at a parotid duct cannulation and infusion procedure to treat painful salivary swelling:

• Prior to the placement of the angiocatheter, I dilated the parotid duct with hollow Marchal dilators. I then placed guidewire into the duct and slid an angiocatheter over guide wire. Next, I removed the guidewire and attached the syringe with steroids. I then infused 2.0-3.0 cc of Kenalog-10.

You should begin by outlining what procedures the physician performs. While the exam header may state that the surgeon performed a cannulation, you see documentation of a catheterization within the operative report. So long as the report documents the introduction of a catheter, as opposed to an intravenous (IV) cannula, you may report any catheterization codes that apply.

In addition to the catheterization, you’ve got documentation of a dilation in order to introduce the catheter. Finally, the surgeon removes the guidewire and attaches the syringe in order to inject 2-3 cc of Kenalog-10. Since you’ve got documentation of both a dilation and a catheterization, you may report code 42660 (Dilation and catheterization of salivary duct, with or without injection).

In the instance that the provider only documents the cannulation without a catheter, you should include the cannulation as a part of the dilation process and report code 42650 (Dilation salivary duct). Natalie Ruggieri-Buzzelli, CPC, CGSC, HIM coding specialist at the Hospital of the University of Pennsylvania’s Department of Otorhinolaryngology, elaborates a little further on the differences between respective procedures. “If the provider opts to dilate with a probe, you’ll want to report code 42650. However, if the provider performs a dilation using a catheter with a subsequent Kenalog injection, you will code the procedure as 42660,” Ruggieri-Buzzelli explains.

Finally, you may report one unit of J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) for the Kenalog-10 injection.

Include Typical Sialolithiotomy Repair in Code 42330

Have a look at this next case study involving a stone removal and subsequent repair:

• After removing the stone from Wharton’s duct, I cleared the field and performed a ductoplasty. Using 6-0 Vicryl suture, I ran a suture medially from the duct’s edge to the epithelium of the floor of the mouth. I performed the same technique contralaterally.

Coding the primary portion of this operative note is relatively straightforward. The surgeon performs a simple sialolithiotomy. Furthermore, the code for a simple sialolithiotomy procedure encompasses all three major salivary glands. You may report a sialolithitomy performed in Wharton’s duct, which is located within the submandibular gland, with code 42330 (Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral).

Next, you’ll want to consider what scenarios, if any, allow for separate reporting of the repair. In the instance that you’re coding either a simple or complex sialolithiotomy repair, you should not report either of the following salivary duct repair codes:

• 42500 (Plastic repair of salivary duct, sialodochoplasty; primary or simple)
• 42505 (… secondary or complicated).

You should reserve 42500 and 42505 for surgical scenarios involving the reconstruction, or repair, of the salivary duct that are unrelated to a concurrent surgical scenario. All simple repairs following sialolithitomies are included in 42330 and 42335 (Sialolithotomy; submandibular (submaxillary), complicated, intraoral). However, if you encounter a clinical scenario involving a complex repair for a simple, or complex, sialolithiotomy, you can consider two options:

For a complex repair following a routine sialolithiotomy, you may append modifier 22 (Increased Procedural Services) to 42330. You should include the operative report and a written explanation justifying the use of modifier 22. You may also consider reporting code 42335 without modifier 22 in some situations in which the repair changes the nature of the surgery from simple to complex. However, if the documentation supports a complex stone removal and/or repair, you should not append modifier 22 to 42335.

Consider Appropriate Modifier for Failed Removal of Stone

Finally, check out this example that involves a failed attempt at a stone removal:

• Following injection of 1% lidocaine and epinephrine, the papilla of the parotid duct was probed using lacrimal probes. Examination revealed a stone 1 cm anterior to the papilla. Massaging attempts to remove the stone were unsuccessful. Attempts at massaging the stone free also failed following the use of scissors to make an incision in the papilla toward the level of the stone.

The appropriate code to report for a routine removal of a stone from the parotid duct is 42330 (Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral). However, as is the case with this example, removal of a stone is not always a guarantee during these procedures.

With respect to coding considerations, the failure to remove the stone does not mean you should report 42330 with modifier 52 (Reduced Services). The work involved in the procedure closely resembles that in which the surgeon would document had the stone been removeable. Similarly, you should not resort to reporting a drainage code, such as 42300 (Drainage of abscess; parotid, simple), in place of 42330. You might encounter surgical reports that detail the drainage of an abscess as a necessary prerequisite for stone removal, but the work in code 42330 does not include the surgeon’s attempts at removing the lodged stone.