Otolaryngology Coding Alert

Question: The surgeon performed a sub-mandibular sialolithotomy to remove multiple stones from the submandibular salivary gland. The procedure was intraoral, but I can't figure out how to differentiate between 42330 and 42335 as the correct code. Can you help?

California Subscriber

Answer: The two codes in question are differentiated by level of complexity:

• 42330, Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral
• 42335, Sialolithotomy; submandibular (submaxillary), complicated, intraoral

You will have to meticulously examine the operative note to determine whether the procedure was routine or complicated. Ultimately, the surgeon makes the final determination as to whether or not the procedure is considered complicated, but that doesn't mean that the coder needs to confer with the provider before making a coding determination. A few factors coders should consider from the operative note are:

• The depth to which the surgeon had to dissect the tissue,
• The amount of tissue removed, and
• The type of repair the provider performed following the removal of the stone.

Typically, each of these points go hand-in-hand with one another. For instance, if the surgeon had to perform a deep dissection of the submandibular gland to reach the stone, more tissue will be removed, resulting in a more complex repair. In addition to these three points, you should also consider time a factor when making a decision on a simple versus complex repair code. If, for instance, the surgeon came across an unusual anatomical variant that significantly extended the length of the procedure, you may consider 42335 over 42330.