Question: Our oral surgeon recently reviewed a 49-year-old male patient with complaints of severe facial pain on the left side. Upon examination and from radiographic studies, our surgeon made a diagnosis of sialolithiasis. He performed a surgical procedure for removal of the stone from the buccal mucosa where the stone was located at the tip of the duct opening. What code should I use to report the procedure that our surgeon performed?
Answer: When reporting the removal of a stone from the salivary gland ducts, you have three codes to choose from:
• 42330 (Sialolithotomy; submandibular [submaxillary], sublingual or parotid, uncomplicated, intraoral)
• 42335 (Sialolithotomy; submandibular [submaxillary], complicated, intraoral)
• 42340 (Sialolithotomy; parotid, extraoral or complicated intraoral)
• A calculus is removed from the submandibular (submaxillary) or parotid salivary gland or duct. This procedure is also referred to as a sialolithomy. In 42330, an uncomplicated, intraoral procedure is performed to remove a calculus from either the sublingual or parotid duct or gland. The papilla of the salivary duct of the involved gland is identified and protected. The mucosa over the duct or gland is incised and the region of the duct or gland containing the calculus is exposed. The salivary gland or duct is incised, and the calculus dissected free of the surrounding tissue. The duct or gland is repaired with sutures as is the overlying mucosa. In 42335 and 42340, a complicated intraoral procedure is performed to remove a calculus from the submandibular duct/gland or parotid duct/gland respectively. Complicated removal typically involves a calculus located at a site that is more difficult to access requiring more extensive dissection of surrounding tissue with identification and protection of surrounding nerves and blood vessels. Complicated removal may also be performed if there are multiple calculi or a very large calculus.
In the case that you have described, since the stone was located in the duct orifice in the buccal mucosa, you will have to look at either 42330 or 42340 as your clinician was removing the stone from the Stensen’s duct (parotid gland duct). Since the stone was located at the tip of the duct, your surgeon would not have to go deep to locate the stone and to remove it. Also, the repair procedure that your clinician would have employed would be a simple closure.
For these reasons, it would be right for you to choose 42330 for the procedure that your clinician performed.
Coding tip: When reporting removal of stones from the parotid gland ducts, you should also check on the approach that your clinician used. If an extraoral approach was used, you will have to report 42340 for the procedure. For an intraoral approach, you will have to look at the complexity of the procedure and choose either 42330 or 42340.