Head & Neck

“CPT copyright 2016 American Medical Association. All rights reserved.

CPT is a registered trademark of the American Medical Association.”

 Head and neck surgery is close to soft tissue and bones as far as CPT coding is concerned. Neuropathology specimens are naturally tied to this section. There are some coding challenges which can summarize other dispersed in previous sections questionable situations.

Head and neck surgery combines a heterogenic group of specimens. This group naturally includes brain tissue.

AMA Manual’s CPT coding

Level III 88304

Cholesteatoma            Conjunctiva-Biopsy/Pterygium         Cornea

               Tonsils and/or Adenoids (older than 14 or 18 years depending on institution)

Level IV 88305

Brain/Meninges, Other than for Tumor Resection

                            Larynx,   Biopsy                           Muscle Biopsy (only H&E)

Nasal Mucosa, Biopsy                                Nasopharyx/Oropharynx, Biopsy 

                                     Nerve, Biopsy (only H&E)

Odontogenic/Dental Cyst                Parathyroid Gland (Usually only on Frozen section)                Pituitary Tumor

                                                   Salivary Gland, Biopsy

      Thyroglossal duct/Brachial Cleft Cyst       Tongue, Biopsy         Tonsil, Biopsy

Level V 88307

Brain, Biopsy                           Brain/Meninges, Tumor Resection

                                 Eye, Enucleation

Larynx, Partial/Total Resection           Odontogenic Tumor (Case #2)      Salivary Gland 

                                             Thyroid, Total/Lobe (Case # 4)

 Level VI

Bone Resection (case #1, 2)

         Larynx, Partial/Total Resection- with Regional Lymph Nodes (Case #3)

        (usually with neck dissection right, left, or both submitted separately)

Soft Tissue Tumor, Extensive Resection (case #1)

                                   Tongue/Tonsil-Resection for Tumor

Suggested codes to unlisted in CPT manual head & neck specimens

 

Descriptor/code Comment
Adenoid (s)/88304Arachnoid –other than tumor/88305Arachnoid, tumor/88307

Brain-other than tumor/biopsy/88305

Clot – hematoma/88304

Cyst –brain/88305

Cyst- thyroglossal duc/88305

Dental cyst/88305

Dura matter- other than tumor/88305

Dura matter, tumor/88307

Epiglottis, biopsy/88305

Hematoma/88304

Nasal polyp/88304

Nasal septum/88304

Nerve-identification only/88302

Nerve, tumor/88307

Neuroma-other than Morton’s/88307

Maxillary tumor/88309

Oral cyst/88305

Paranasal biopsy/88305

Pharynx biopsy/88305

Pharynx, tumor/88307

Pia matter-other than tumor/88305

Pia matter tumor/88307

Pterygium/88304

Sinus contents/88305

Sinus cyst/88304

Sinus mucosa stripping/88305

Sinus polyp/88305

Soft/hard palate, biopsy/88305

Spinal cord, biopsy/88305

Spinal cord, tumor/88307

Surgical margin88305

Turbinate/nasal conchae/88304

Uvula/Soft palate, simple excision/88302

Uvula,biopsy/ 88305

Vascular malformation/ 88305

Older than 14 or 18 years per institution 

Epilepsy, trauma

 

 

 

 

 

 

 

 

 

 

 

e.g. vagus

 

e.g. schwannoma

bone/soft tissue

 

 

 

 

 

 

 

e.g. ethmoid, mucosa, turbinate

 

except pseudocyst

 

 

 

 

 

 

 

sleep apnea

 

arteriovenous malformation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case #1   Radical maxillectomy

A 68-year-old man underwent a radical left maxillectomy with left neck dissection due to sarcoma. There were submitted 13 specimens including 4 frozen sections of the margins.

There is no a specific descriptor for this type of specimen. It is both, bone resection and soft tissue tumor/cancer.

Accession

 

S/# Specimen description CPT code
A, B, C, D Frozen sections-margins   from nasal vestibule, trigeminal nerve, superior margin ethmoid, sphenoid 88331 x 4Level IV 88305 x 4
E Coronoid process of   mandible Level VI 88309
F Left neck dissection Level V 88307
G Radical maxillectomy Level VI 88309
H, I, J, K Margins : Superior parotid   margin; Mucosa around; Eustachian tube; Posterior orbital tissue; Buccal and   lip mucosa Level IV 88305 x 4
L Ethmoid mucosa Level IV 88305
M Left pterygoid Level VI 88309

 

 

S/# Specimen description CPT code
A, B, C, D Frozen section-margin from   nasal vestibule-Positive for tumor margin   trigeminal nerve- nerve, negative for malignancy superior margin   ethmoid-benign respiratory mucosa sphenoid- benign respiratory mucosa 88331 x 4Level IV 88305 x 4
E Coronoid process of   mandible-margin, excision-  multiple fragments   of bone and minute fragments of attached soft tissue (1.3×1.3×0.4 cm) –   negative for tumor Level IV 8830588311
F Left neck dissection-   fragment of soft tissue (3.5x 2.5×0.6 cm); 18 lymph nodes negative for tumor Level V 88307
G Radical maxillectomy-   sarcoma with smooth muscle differentiation (leiomyocarcoma) 6.0×5.2×4.0 cm   arising in the maxillary sinus and invading through the bone the nasal   cavity; anterior and posterior margins of resection are positive for   malignancy. Level VI 8830988311Level VI 8309 88342 x1188313 x1
H, I, J, K Superior parotid margin of   left maxillectomy – benign tissue Mucosa around Eustachian tube- no evidence   of malignancy Posterior orbital tissue-no evidence of malignancy Buccal and   lip mucosa- fragment of soft tissue 7.2×0.4×0.3 cm Level IV 88305 x 4
L Ethmoid mucosa- left   maxillectomy- fragments of bone tissue 1.0×0.5×0.4 cm, fragments of soft   tissue 1.0×1.0x03 cm decalcification – no evidence of malignancy Level IV 88305 88311
M Left pterygoid- a bone   structure 2.0×1.5×1.0 cm with attached soft tissue 2.0×1.5×1.0 cm- the bone   structure serially sectioned, submitted in cassettes T2-T5 with   decalcification Level VI 8830988311

 

 

 

Specimen E constitutes margin examination with bone fragments in opposite to specimen M where bone resection was performed that had also margins examination purpose. Specimen H – radical maxillectomy has two components as Level VI 88309 Bone Resection and Level VI 88309 Soft Tissue, Tumor, Extensive Resection although two codes for charge can be disputed. Immunoperoxidaze stains are not limited as a medical necessity.

Case # 2    Odontogenic tumor with mandibulectomy

A 33-year-old man underwent hemimandibulectomy due to odontogenic tumor. Four margins were examined on frozen sections.

Accession

 

S/# Specimen description CPT code
A, B, C, D Frozen section- right   mandible soft tissue, medial margin lateral margin posterior 88331 x 4; Level IV 88305 x   4
E Right facial node Level V 88307
F Right mandible Level VI 88309
G Bone anterior margin Level IV 88305

Final billing code after pathologist’s report

 

S/# Specimen description CPT code
Frozen section- right   mandible soft tissue-calcifying epithelial odontogenic tumor; medial lateral   posterior margin- negative for malignancy
E Right facial node – one   lymph node (2.0×1.6×0.6 cm) –reactive hyperplasia Level IV 88305
F Right mandible- calcifying   epithelial odontogenic tumor (Pinborg) 3.5×2.5×2.4 cm involving mandible; the   margins of resection are free of tumor. Level VI 8830988311Level V 88307
G Bone anterior margin   –negative for malignancy Level IV 8830588311

 

Specimen E, facial node, is a biopsy but not a resection by the procedure. The CPT manual has a descriptor Level V 88307 Odontogenic tumor as in this case. The use of second code would be justified.

Case # 3   Laryngoectomy

A 74-year-old man underwent laryngoparyngectomy accompanied with hemimandible resection due to carcinoma. There were 12 Frozen section performed on margins.

 Accession

 

S/# Specimen description CPT code
A-L  Frozen section margins 88331 x 12Level IV 88305 x 12
M Marrow proximal mandible Level IV 88305
N Tracheal stoma tissue Level III 88304
O Left modified neck   dissection Level V 88307
P Right modified neck dissection Level V 88307
Q Left composite resection Level V 88307
R Laryngopharyngectomy Level VI 88309

 

Final billing code after the pathologist’s report

 

S/# Specimen description CPT code
 A-L  Frozen section margins 88331 x 12 Level IV 88305
M Dictal mandible marrow, negative for malignacy 88311
N Tracheal stoma tissue,   excision multiple fragments 0f fibrous tissue 4.5×2.5×0.7 cm- negative for   malignancy Level III 88304
O Left modified neck   dissection- 2  out of 37 lymph nodes positive  for squamous cell carcinoma Level V 88307
P Right modified neck   dissection- one of 22 lymph nodes positive for squamous cell carcinoma Level V 88307
Q Left composite resection-   hemi-mandible- squamous cell carcinoma, involving the buccal mucosa, gingival,   adjacent salivary gland and underlying mandible bone Level VI 8830988311
R Laryngopharyngectomy-   moderately to poorly differentiated squamous cell carcinoma of the   hypopharynx Level V 88307

Bone specimens M and Q haven’t been recognized during accession. Only Larynx, Partial/Total Resection- with Regional Lymph Nodes is Level VI 88309. Usually larynx is Level V 88307 because regional lymph nodes arrive separately as neck dissection Level V 88307. In this case also both neck dissections were presented in specimens O and P.

Case # 4   Thyroidectomy

A 49-year-old woman underwent thyroidectomy that was accompanied with 9 frozen sections.

Accession

 

S/# Specimen description CPT code
A-L  Frozen section margins-negative  for malignancy 88331 x 12Level IV 88305 x 12
M Distal mandible marrow,   biopsy- negative for malignancy Level IV 8830588311
N Tracheal stoma tissue,   excision multiple fragments 0f fibrous tissue 4.5×2.5×0.7 cm- negative for   malignancy Level III 88304
O Left modified neck   dissection- 2  out of 37 lymph nodes positive  for squamous cell carcinoma Level V 88307
P Right modified neck   dissection- one of 22 lymph nodes positive for squamous cell carcinoma Level V 88307
Q Left composite resection-   hemi-mandible- squamous cell carcinoma, involving the buccal mucosa, gingival,   adjacent salivary gland and underlying mandible bone Level VI 8830988311
R Laryngopharyngectomy-   moderately to poorly differentiated squamous cell carcinoma of the   hypopharynx Level V 88307

Final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A, B, C, D, E Frozen section-Right   superior parathyroid- parathyroidectomy; benign parathyroid tissue; right mid   cervical lymph node- one 0.4×0.4×0.3cm lymph node; negative for malignancy;   left superior parathyroid-parathyroidectomy; benign parathyroid tissue;   inferior pretracheal central cervical lymph node-two 0.4×0.3×0.2 cm and   0.3×0.3×0.2 cm – benign tissue; left inferior parathyroid- parathyroidectomy-   benign parathyroid tissue; 88331Level IV 88305
F Frozen section- right   inferior thyroid nodule- thyroidectomy; nodule 2.5×2.5×1.5 cm lymphocytic   thyroiditis 88331Level IV 88305Level V 88307
G Frozen section- right   superior thyroid-hyoidectomy; tissue 1.6 x 1.5 x 1.3 cm-lymphocytic   thyroiditis 88331Level IV 88305Level V 88307
H Frozen section-right   thyroidectomy- lobe 4.8X2.7×2.1 cm-lymphocytic thydoiditis in the background   of nodular hyperplasia. One benign parathyroid gland. 88331Level IV 88305Level V 88307
I Right cervical thymus,   excision-yellow –tan tissue 0.74 gm, 1.7 x1.4 x 0.5 cm-benign thymus tissue   with small cyst (0.3 cm) Level IV 88305
J Right superior parathyroid-   parathyroidectomy- benign parathyroid tissue. Level IV 88305

Specimens B, C, and D required additional thyroid examination after the frozen section that is Level V 88307 Thyroid, Total/Lobe. The parathyroid specimens were completely examined during frozen sections. The parathyroid gland in specimen D does not constitute a separate code charge as a part of the main specimen. Thymus is not incidental for gross only, as well as not Level V 88307 Thymus, Tumor hence Level IV 88305 as a biopsy is justified. All lymph nodes were submitted during frozen section and they are biopsies in this surgery anyway.

Head and neck specimens are results of complicated surgery. They are not simple for CPT coding because there are many different components which are unlisted in the CPT coding manual. These specimens require more pathologist’s and billing manager’s attention.

Disclaimer

 These materials do not represent official advice of the CAP, AMA, CMS or other governmental institution. The information will not bear any liability for its application and will not prevent any dispute with a third-party payer.

 

 

 

 

 

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>