Otolaryngology Coding Alert

You Be the Coder: How Should I Report Salivary Stone Removal?

- Published on Fri, Mar 24, 2006
Reviewed on May 15, 2015
Question: How should I report removal of salivary stones from the submandibular salivary gland?

Nevada Subscriber

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.This diagnosis will change to K11.5 (Sialolithiasis) under ICD-10.

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.

Get 14-Day Fully-Functional Free Trial of Physician Coder

Get access to all your specialty alerts and archived articles along with some comprehensive tools including:
  • Code Search for CPT®, HCPCS, ICD-9 and ICD-10
  • CCI Edits Checker
  • Part B Fees, MUEs
  • CPT-ICD-9 CrossRef
  • CPT® ↔ ICD-9 ↔ ICD-10 CM Crosswalk
  • LCD/NCD Lookup
  • CMS 1500 Claims Scrubber
  • NDC ↔ CPT/HCPCS CrossReference
First Name: *
Last Name: *
User Name: *
E-mail: *
Phone: *
Choose Speciality*
Please enter the characters shown in box*