Camille Posted Mon 09th of December, 2019 18:29:41 PM
Procedure: Excision of lesion of floor of mouth, Sialodochoplasty, Mucosal Graft. Resection of squamous cell cancer: A bite block was placed. 6 cc of local anesthetic were injected into the right floor of mouth. A mucosal and gingival incision was made around the lesion with a 5-7 mm margin of normal appearing mucosa. The lesion was dissected free of surrounding and deep soft tissue and removed. The cut edge of the right submandibular duct was identified and tagged. Mucosal margins were harvested and sent for frozen section analysis. There was suspicion of microscopic disease at the medial margin. Additional tissue was resected and an additional medial margin was sent.
Sialodochoplasty: The cut edge of the salivary duct was enlarged by incising the duct longitudinally for 5 mm. The mucosal edges were reapproximated to the adjacent tongue mucosa anteriorly.
Flap reconstruction. Mucosa was elevated from the oral tongue. This flap of tissue was advanced into the defect and approximated with the gingival mucosa.
Estimated blood loss for the procedure was 50 cc. The patient tolerated the procedure well. There were no complications. QUESTIONS: 1) The Sialodochoplasty (CPT 42500) seems necessary due to the excision of the lesion. It doesn't bundle, but should it be billed with the lesion excision (CPT 4116?) 2) Is the mucosal flap graft also included in the closure for the lesion excision? Thank you kindly.
SuperCoder Answered Tue 10th of December, 2019 13:31:21 PM
Our team is working on your query. Will get back to you soon.
SuperCoder Answered Thu 12th of December, 2019 13:31:10 PM
Thank you for you patience.
As per CPT® instructions, ATT/R (adjacent tissue transfer or repair) procedures include excisions at the same location—for instance, to revise a scar or to remove a benign or malignant lesion. So, seeing the above procedure where the mucosal edges were reapproximated to the adjacent tongue mucosa anteriorly. Flap reconstruction. Mucosa was elevated from the oral tongue. This flap of tissue was advanced into the defect and approximated with the gingival mucosa, the appropriate code to bill will be 14040.
NOTE: we will not bill excision code if we are billing for ATT as it includes defect or excision codes.
Also, >Report ATT/R (14000-14350) only if the surgeon freed any tissue from another site or from around the damaged area, and transplanted or rearranged the tissue to overlay and repair the wound.
Feel free to ask for any further query.
Camille Posted Fri 13th of December, 2019 14:04:41 PM
Thank you very much! Very helpful!
SuperCoder Answered Sun 15th of December, 2019 23:27:04 PM