Question Excsion submandibular mass, gland , and cervical lymph node

suchang78

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Dx: right submandibular mass and right cervical lymphadenopathy

Procedures: resection of right submandibular mass with limited cervical lymph node dissection

A right neck incision 2 fingers below the mandibular angle was marked with a marking pen and then subcutaneous tissue was injected with 1% lidocaine with epinephrine about 9cc. after that, the skin incision was made using the #15 blade and about a 4cm incision was created horizontally. after that, the incision carried through the platysmal layer and the platysma flap was elevated superiorly and inferiorly. then dissection bluntly with the curved Metzenbaum scissor and the jugular area was dissected. The SCM muscle was isolated and retracted posteriorly and then the submandibular space was exposed. the submandibular sheath was opened and the submandibular gland was identified and then dissected, pushed way toward the anterior. then dissected deeper to the posterior submandibular gland, and deep to the SCM muscle, and elongated mass was identified and then the surrounding vascular tissue and soft tissue were also resected and then the entire mass was isolated and the delivered in a single piece. bleeding underneath was cauterized and the mass was sitting just anterior to the carotid space.

Limited cervical lymph node dissection was then carried out using blunt technique and the furthest SCM muscle was retracted posteriorly and then the jugular sheath was exposed. Then dissected it inferiorly to the level 2 cervical lymph node group and the carotid sheath was then opened. at the level 2 jugular chain, there were 2 large lymph nodes identified and the removed using Metzenbaum scissor bluntly and more dissection below did not result in significantly enlarged lymph nodes. then the major specimen was send down to the frozen section, it appears to be lymphatic tissue and no obvious malignancy was seen.

In pathology report :
1. right submandibular mass ( benign lymph node)
2. right jugular node ( benign lymph node)

I assign
1. 38510 for cervical lymph node excision
2. 42440 - excision submandibular gland

Do I need to assign another code for submandibular mass removal ( 21556/21554), or the 42440 is included the mass removal already?

Please advice.

Thank you.
 

b.cobuzzi

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It looks like more than just the submandibular gland was removed. The surgeon continued deeper and removed a mass deep in the SCM muscle. Since the surgeon did not document the size of the tumor, I would stick with 21556 for less than 5cm. You can’t code the larger size without documentation of the size. I checked the bundling and 42440 and 21556 are not bundled.
 
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