Otolaryngology Coding Alert

Question: How would you code a laryngectomy with bilateral modified radical neck dissections?

Mississippi Subscriber

Answer: First, let’s differentiate between a radical neck dissection and a modified radical neck dissection:

Radical neck dissection (RND): Surgical procedure in which the provider removes a mass such as a tumor from the neck, along with an additional edge of tissue that seems normal; he also removes the lymph nodes from the neck.

Modified radical neck dissection (MRND): Procedure to remove the lymph nodes and additional muscle and soft tissue in the neck but with extra work to preserve the spinal accessory nerve, jugular vein, and sternocleidomastoid muscle.

So, essentially the modified radical neck dissection incorporates radical neck dissection in addition to the extra work it takes to preserve the three listed structures. At first glance, the answer might appear to be 31365 (Laryngectomy; total, with radical neck dissection).

However, noting the differences between the two neck dissections leads you to find an alternative set of codes to document both procedures. Since there is no laryngectomy code that includes a modified radical neck dissection, you’ve got to apply two individual codes. The correct code selections would be:

• 31360 (Laryngectomy; total, without radical neck dissection) for the laryngectomy
• 38724 (Cervical lymphadenectomy [modified radical neck dissection]) for the lymphadenectomy
• Modifier 50 (Bilateral procedure) appended to 38724 to indicate the bilaterality of the procedure
• Modifier 59 (Distinct procedural service) appended to 38724 to indicate that the lymphadenectomy is a separate procedure from the laryngectomy.

Check CCI edits: When pairing codes such as these, don’t forget to check the Correct Coding Initiative (CCI) edits to make sure they are compatible. In this case, you can override the edit using modifier 59 since the physician performs MRNDs on separate sites from the laryngectomy. Furthermore, the use of 31365 is not appropriate because an RND does not document the full extent of work involved with performing an MRND. If a payer requests that you submit coding for these procedures in such a way, an appeal with documentation supporting codes 31360 and 38724-50 and -59 is recommended.

Finally, remember that 38724 is an inherently unilateral code, so application of a bilateral modifier 50 is necessary in this instance.