Otolaryngology Coding Alert

When your otolaryngologist performs a tongue biopsy, lesion excision, or resection — for example, to aid in the diagnosis of lingual cancer or as a treatment for obstructive sleep apnea — you’ll need to be armed with some anatomical and procedural facts and code know-how to avoid letting hard-earned dollars fall through the cracks.

Read on for a medical terminology refresher and a deep dive into code choices and coding rules to help you code every case correctly and garner the pay your surgeon deserves.

Learn the Lingo

Medical record documentation for tongue procedures may include a wide variety of terms — some familiar and some unfamiliar. Being able to interpret your otolaryngologist’s documentation and land on the right CPT^® code hinges on you knowing the following definitions and the details that set these terms apart. Study this glossary to help you translate the op note to the CPT^® terms that guide your code selection.

Anatomy

• Oral tongue – the anterior (front) two-thirds of the tongue
• Base of the tongue – the posterior (back) one-third of the tongue, which is part of the oropharynx (portion of the throat posterior to the oral cavity), not the mouth

Procedures

• Biopsy – removal of a sample of cells or tissue for diagnostic purposes, not as a treatment to remove all diseased tissue.
• Excision – removal of the entire area of diseased tissue, such as a lesion, with clear margins as a surgical treatment.
• Glossectomy – surgical removal of all or part of the tongue, usually due to cancer or precancerous changes. Glossectomy comes in the following forms:

o Partial – removal of part of the tongue

o Hemi – removal of one side of the tongue

o Total – removal of the entire tongue

• Resection – surgical removal of all or part of an organ or other structure. “Surgeons will often use this term interchangeably with the term excision when referring to the surgical removal of an organ,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

Be Familiar With Tongue Code Families

Biopsy: The portion of the tongue from which the lesion is biopsied distinguishes these two codes from one another, as follows:

• 41100 (Biopsy of tongue; anterior two-thirds)
• 41105 (... posterior one-third)

Lesion Excision: Knowing the site and whether the procedure includes closure allows you to correctly designate one of the following codes:

• 41110 (Excision of lesion of tongue without closure)
• 41112 (Excision of lesion of tongue with closure; anterior two-thirds)
• 41113 (... posterior one-third)
• 41114 (… with local tongue flap)

Coding tip: If your otolaryngologist excises a tongue lesion without closing the wound site, you should report 41110 regardless of the location on the tongue. Use 41114 if the surgeon uses flap closure, but use 41112 or 41113 for primary closure, which is more common.

Tongue Resection: The op note for a tongue resection will describe a more extensive procedure than a lesion excision. “Look for the following information in the note to identify the service as a resection and to help you choose the appropriate procedure code,” advises Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, revenue cycle director for Clinical Health Network for Transformation in Houston, Texas:

• The extent of tongue structure removed
• Whether the procedure extended to a neck dissection
• Whether the surgeon removed part of the floor of the mouth
• Whether the resection involved the mandible

CPT^® provides eight glossectomy codes for you to select based on the preceding information from the op note:

• 41120 (Glossectomy; less than one-half tongue)
• 41130 (… hemiglossectomy)
• 41135 (… partial, with unilateral radical neck dissection)
• 41140 (… complete or total, with or without tracheostomy, without radical neck dissection)
• 41145 (… complete or total, with or without tracheostomy, with unilateral radical neck dissection)
• 41150 (… composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection)
• 41153 (… composite procedure with resection floor of mouth, with suprahyoid neck dissection)
• 41155 (… composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type))

Coding tip: You may separately report any documented reconstruction, such as grafts, in addition to the resection code.

Note: “These combination codes pair tongue resection with radical neck dissections (RNDs) only. Because of this, a modified radical neck dissection (MRND) is bundled with all of the tongue resection codes, pushing the coder to use these combo codes that include RND,” Cobuzzi notes. “But most surgeons today do not perform RNDs.” Instead, they opt for glossectomy with MRND when possible, she adds.

Try Your Hand at This Tongue Case

Read the following note and see if you can assign the correct procedure and diagnosis codes.

Procedure: A 42-year-old established patient complains of a white patch on the back of his tongue that is slightly painful. He is currently a smoker but does not use alcohol. Upon examination, the otolaryngologist notes a 2.8 cm white lesion with a slightly ulcerated surface on the lateral border of the posterior third of the tongue with normal-looking surrounding tissue. After numbing the area, the surgeon uses a scalpel for sharp removal of a 7 mm portion of the ulcerated lesion, closing the site with two sutures.

Code: The correct procedure code for the case is 41105 because the note describes a biopsy of a lesion on the posterior tongue region. This choice is clear from the op note, even if the surgeon didn’t use the term, “biopsy.” “The note clearly describes removal of a portion of a larger lesion, which makes this a biopsy,” says Brame-Joy. “Don’t let the mention of closure fool you into choosing a lesion excision code,” she continues.