Otolaryngology Coding Alert

Question: Which code should we use when we excise a submental mass?

New York Subscriber

Answer: It’s difficult to say without seeing the operative note, but you should probably use one of the following codes, depending on where the mass was and how the otolaryngologist removed it:

• 15838 -- Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad
• 21555 -- Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm
• 21556 -- Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm
• 41007 -- Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space
• 41016 -- Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental.

Although 15838 refers specifically to an excision involving the submental space, this procedure is often considered cosmetic (for example, it may be difficult to collect payment even when the excision is medically necessary). And 15838 describes excising a fat pad (such as a lipectomy), not a mass.

Codes 21555 and 21556 also describe excisions, but they refer specifically to tumors, not the more generic term "mass." And although the submental space is close to the neck, it is a separate site, and carriers may determine that these neck and thorax procedures do not apply.

Codes 41007 and 41016 describe incision and drainage (I&D) of a submental mass. The codes differ in that the physician drains the mass either from inside the mouth (41007) or externally (41016). In your case, the physician excised the submental mass and did not perform an I&D. Although it is unlikely, some carriers may accept modifier 22 (Increased procedural services) (if documented properly) and pay more for the excision.

Your payer may prefer that you report unlisted-procedure code 40899 (Unlisted procedure, vestibule of mouth) or 21899 (Unlisted procedure, neck or thorax). You should wait for the pathology report before you select a CPT^® code for this procedure, because the lab results may provide more information to help you select the correct code.