Question: How should I report removal of salivary stones from the submandibular salivary gland?
Answer: Removal of salivary stones is called sialolithotomy, and CPT contains three codes to describe these procedures, depending on the location/depth and complexity of the procedure:
- 42330--Sialolithotomy; submandibular (sub-maxillary), sublingual or parotid, uncomplicated, intraoral
- 42335--... submandibular (submaxillary), complicated, intraoral
- 42340--... parotid, extraoral or complicated, intraoral.
You-ll probably use a diagnosis of 527.5 (Sialolithiasis) along with 42330-42340.
If the ENT uses an endoscope (for example, 31575, Laryngoscopy, flexible fiberoptic; diagnostic) at a different session to locate the stones, you may report the endoscope and office visit separately.
You should add modifier 25 (Significant, separately identifiable E/M services by the same physician on the same day of the procedure or other service) to the office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) in which the otolaryngologist diagnoses the patient with a submandibular salivary gland stone. This assumes, of course, that the physician did provide and document a separately identifiable office visit and that the procedure was not already scheduled.