Take a Deep Dive Into Neck Dissection Coding
Beware bundling issues with total laryngectomies and glossectomies. Neck dissections are procedures intended to remove some or all of the lymph nodes in various areas of the neck as part of the treatment for certain head and neck cancers. But you can easily code and bill these complex surgeries if you follow these four steps. First, Understand the Lymph Node Levels As the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) explains, lymph nodes are located in nine different zones, known as levels, in the neck: Then, Understand Dissection Types and Their Related CPT® Codes The AAO-HNS also identifies four different neck dissection types. Here they are, along with the relevant CPT® codes you should use to report them: Radical neck dissection (RND), coded to 38720 (Cervical lymphadenectomy (complete)), involves removal of all cervical lymph node groups from levels I through V, along with removal of the ipsilateral spinal accessory nerve (SAN), sternocleidomastoid muscle (SCM), and internal jugular vein (IJV). RND is referred to as “radical” because the surgeon removes almost all the lymph nodes on one side of the neck, from the jawbone to collarbone, as well as muscles, nerves, and veins. Modified radical neck dissection (MRND), coded to 38724 (Cervical lymphadenectomy (modified radical neck dissection)), is the most common neck dissection. It involves removal of all lymph node groups routinely removed in an RND on one side of the neck, but with preservation of one or more nonlymphatic structures. When one or more of the other structures — SAN, SCM, IJV — removed during an RND dissection is spared, the procedure is considered MRND. Suprahyoid neck dissection (SHND), coded to 38700 (Suprahyoid lymphadenectomy), involves removal of only the Level I nodes (submental and submandibular nodes) that lie above the hyoid bone and the submandibular gland. Simply put, an SHND is a partial or selective neck dissection that removes a few lymph nodes closest to the tumor. Remember, if your provider also performs a submandibular gland resection, that procedure is bundled into 38700, so you will not be able to report 42440 (Excision of submandibular (submaxillary) gland) separately with 38700. Selective neck dissection (SND) involves the removal of a subset of lymph node groups (levels) routinely removed in an RND or MRND. In other words, the operation does not involve all five zones. SND typically preserves nonlymphatic structures (SAN, SCM, and IJV) but may also involve their sacrifice. Coding will depend on the extent of node removal. Examples of SND include: For SND, you’ll use the MRND code 38724 as the procedure does not involve removing lymph node levels I-V and it also preserves one or more nonlymphatic structure. Extended radical neck dissection (ERND) “refers to the removal of one or more additional lymph node groups or nonlymphatic structures, or both, not encompassed by the radical neck dissection,” according to AAO-HNS. “Examples of such lymph node groups include the parapharyngeal (retropharyngeal), superior mediastinal, perifacial (buccinator), and paratracheal lymph nodes. Examples of the nonlymphatic structures include the carotid artery, overlying skin, hypoglossal nerve, vagus nerve, and paraspinal muscles,” the AAO-HNS adds. Coding for ERND depends on what, exactly, the surgeon removes during the procedure. If the provider performs all the RND services described by 38720 and removes the additional lymph node groups and nonlymphatic structures specified in the AAO-HNS definition of ERND above, you can use 38720 with modifier 22 (Increased procedural services). Alternatively, if the procedure the provider performs preserves one or more of the SAN, SCM, and IJV structures but removes other nonlymphatic structures as specified in AAO-HNS’s description of ERND, you should use 38724 with the 22 modifier. Next, Check to See if the Service Is Bilateral Neck dissections are unilateral procedures. This means you should defer to payer guidelines regarding billing for bilateral procedures with a unilateral code, and use either modifier 50 (Bilateral procedure) or XS (Separate structure …) on the code; or, list the code on two separate lines with modifier 59 (Distinct procedural service) appended to the second code should the provider perform the procedures on both sides of the patient’s neck. Last, Correctly Bill for Bundled Services Surgeons commonly perform a total laryngectomy or total glossectomy in conjunction with an RND or MRND for cancer patients to make sure that they remove all of the diseased tissue. Code selection for this will depend on the type of dissection. For removal of the larynx and RND, you’ll use the bundled code 31365 (Laryngectomy; total, with radical neck dissection). For removal of the tongue and RND, you’ll use the bundled code 41145 (Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection). CPT® lacks a code that combines a laryngectomy/glossectomy with MRND, so you’ll have to separately bill the procedures. So, you’ll use 38724 for the MRND with either 31360 (Laryngectomy; total, without radical neck dissection) or 41140 (Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection). However, National Correct Coding Initiative (NCCI) edits bundle MRND into laryngectomy and glossectomy procedures, so you will have to use either modifier XU (Unusual non-overlapping service …) or modifier 59 with 38724 when billing with 31360 and/or 41140 per payer guidelines as appropriate. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
