Wiki CPT code for excision of pre-auricular mass

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mrolf

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Scenario: Longitudinal incision measuring 2 cm made and carried down through the subq tissues in the pre-auricular region. Temporal branches of the facial nerve were directly over the palpable mass. These were bluntly dissected to either side of the mass. Mass was then sharply and bluntly dissected away from surrounding tissues. While dissecting the mass did rupture spilling some clear viscous fluid. This was removed and sent with the specimen. The cyst itself was then sharply excised down to its base. The posterior wall of the cyst was cauterized again. Wound irrigated. Two small metal clips were deep within the cavity and had been used earlier to assist with hemostasis. Closed with Prolene. Path report came back stating "soft tissue of rt. periauricular area, excision of mass: Hyalinized fibroconnective tissue with areas of calcification and osseous metaplasia.Negative for maligancy.

The surgeon wants to use CPT code 42410. I was thinking 21555. Looking for another person's view. Please advise. Thanks.
 
Actually, I think your physician is correct. 42410 should be coded. From a coder's perspective, he could have been a little more descriptive by stating it was a "parotid tumor", but I'm pretty sure that a pre-auricular mass is considered to be a parotid tumor. :)
 
I beg to differ, the pathology indicated "Hyalinized fibroconnective tissue with areas of calcification and osseous metaplasia. Negative for maligancy"; it did not indicate a "parotid tumor" nor did the surgeon mention the parotid at all; I would suggest you look at CPT 21013 or 21014, Excision, tumor, soft tissue of face and scalp, subfacial (eg, subaleal, intramuscular): less than 2 cm or 2 cm or greater.

Jennifer
CT ENT
 
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