Otolaryngology Coding Alert

Question: An otolaryngologist uses an endoscope to examine a patient's salivary gland and duct. Based on the exploration, he diagnoses the patient with a submandibular salivary gland stone. He takes the scope out and later in a separate procedure removes a salivary stone. Which CPT code(s) should I report?

Texas Subscriber

If the endoscopy is separately identifiable from the open sialolithotomy, you should code the diagnostic procedure, the surgical procedure, and the office visit.

For the salivary stone removal, you should chose one of the following:
  42330 - Sialolithotomy; submandibular (submax-illary), sublingual or parotid, uncomplicated, intraoral
  42335 - ... submandibular (submaxillary), complicated, intraoral
  42340 - ... parotid, extraoral or complicated, intraoral. Use the appropriate endoscopy code, such as 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). To indicate that the otolaryngologist performed the endoscopy at a separate session from the salivary stone removal, append modifier -59 (Distinct procedural service) to the endoscopy code.

You may also append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) in which the otolaryngologist diagnoses the patient with a submandibular salivary gland stone. If the otolaryngologist needed to perform endoscopy to reach a definitive diagnosis, you should report the E/M service in addition to the endoscopy, provided the otolaryngologist performed and documented a separately identifiable office visit.