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sialadenitis question - Findings: cystic tissue

  1. Talking sialadenitis question - Findings: cystic tissue
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    Hello all,

    Findings: cystic tissue adjacent to Wharton duct on the left going up underneath the surface of the tongue. approx 2 to 3 cm in size

    Path came back Sialadenitis with ductal estasia

    lacrimal probes were used to dilate the Wharton duct. After that was achieved the cystic tissue was retracted w/ forceps, and excised with guarded needle tip coagulation cautery.

    42650 for dilation but having a hard time find a CPT for the "excision"???
    Anyone w/ ideas??


  2. Default sialadenitis question

    I could not find an exact code. I was looking at 42440 but that is for removal of the submandibular gland itself (which the Wharton or submandibular duct drains saliva from). Your documentation states cystic tissue was removed. So, the only other option that I can see is to use 42699 (unlisted procedure, salivary glands or ducts) and submit the documentation with the claim. And, also code the dilation (42650) as you already have found.

    Also look at code 42665 Ligation of salivary duct, intraoral. The description for this code is: "The physician makes an intraoral incision overlying a salivary duct and dissects to the layer of the duct. The duct is ligated (tied) and incision is closed." Based on the closure that your provider performed, you may be able to use this code. You could query your provider to find out if this code would be appropriate for the procedure.

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