Otolaryngology Coding Alert

Reviewed on May 12, 2015 

Question: Which CPT code should I use for surgical excision of a salivary cyst on the lower lip? Code 42408 says a sublingual salivary cyst. Should I use an unspecified procedure or excision code for the lip? The pathology report says -mucocele.-

Louisiana Subscriber

Answer: A pathology report of mucocele (527.6)  indicates a dilated salivary gland cavity filled with mucous, a diagnosis that supports a code for vestibule of mouth excision (40810-40816, Excision of lesion of mucosa and submucosa, vestibule of mouth -). The American Association of Oral and Maxillofacial Surgeons (AAOMS) lists 40810-40816 as surgical treatment options for 527.6, which includes -retention cyst of salivary gland.-

Example: You should code removal of a lesion on the lip's vestibular mucosa without repair with 40810 (- without repair) and 527.6, When ICD-10 becomes effective, you’ll submit diagnosis K11.6 (Mucocele of salivary gland).

The mouth's vestibule is the part of the oral cavity outside the dentoalveolar structures, and it includes the mucosal and submucosal lip and cheek tissue, according to CPT's Vestibule of Mouth introductory notes.

Alternative: If the otolaryngologist -makes an incision through the skin, undermining the subcutaneous tissue, beneath the lesion to remove the lesion,- you should instead use an integumentary excision code, such as 11440 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less), the AAOMS says.

Because the cyst excision occurs on the lip, not on the floor of the mouth, you should rule out 42408 (Excision of sublingual salivary cyst [ranula]). Code 42408 describes removal of a sublingual (beneath the tongue) salivary cyst during which the otolaryngologist makes an intraoral incision in the floor of the mouth overlying the cyst and then removes the cyst.