Otolaryngology Coding Alert

Question: How should I code a removal of a lesion on the lip's vestibular mucosa without repair? The pathology report says "mucocele." Can I bill 42408?

Answer: You should report the lesion removal with excision code 40810 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair), and link to ICD-9 527.6 (Mucocele of salivary gland), which indicates a dilated salivary gland cavity filled with mucous. The vestibule of mouth (oral vestibule) is the anterior most portion of the oral cavity, according to the website enotes. com. It's the space between the cheek/lips and the teeth.

In this case, 42408 (Excision of sublingual salivary cyst [ranula]) is not appropriate since the cyst excised was on the lip, not on the floor of the mouth. This code describes removal of a sublingual (beneath the tongue) salivary cyst.

Quick fact: Unlike skin lesion excision codes, oral lesion excision codes have the wound closure built in - so there is never any need to report a separate code for closure. You can choose from closure types i.e., "without repair," "simple repair" and "complex repair."