How To Use CPT Code 42330

CPT 42330 describes the surgical removal of a stone from the salivary gland through an intraoral approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 42330?

CPT 42330 is used to describe the surgical removal of a stone from the salivary gland through an intraoral approach. This procedure is performed by a physician and involves the removal of a calculus (stone/concretion) from a salivary duct or gland. The incision is made within the mouth, and if the stone is large, a portion of surrounding tissue may also be removed. The wound is then closed over a drain. This is a relatively simple procedure.

2. Official Description

The official description of CPT code 42330 is: ‘Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral.’

3. Procedure

1. The physician performs an intraoral incision to access the salivary gland.
2. A calculus (stone) within the salivary duct or gland is identified.
3. The physician removes the calculus using surgical instruments.
4. If the size of the stone is large, a portion of surrounding tissue may also be removed.
5. A drain may be placed to facilitate proper healing.
6. The wound is closed using sutures or other appropriate closure methods.

4. Qualifying circumstances

CPT 42330 is used for the uncomplicated surgical removal of a stone from the submandibular (submaxillary), sublingual, or parotid salivary glands. The procedure is performed intraorally, meaning it is done within the mouth. The patient must have a salivary gland stone that requires surgical intervention. The physician performing the procedure must document the specific location of the stone and any additional details that may be relevant to the case.

5. When to use CPT code 42330

CPT code 42330 should be used when a physician performs an uncomplicated intraoral sialolithotomy to remove a stone from the submandibular (submaxillary), sublingual, or parotid salivary glands. It is important to note that this code is specifically for uncomplicated cases. If the procedure is complicated or involves a different approach, other codes should be used.

6. Documentation requirements

To support a claim for CPT 42330, the physician must document the following information:

• Specific location of the stone (submandibular, sublingual, or parotid)
• Description of the stone and its size, if applicable
• Details of the surgical approach and technique used
• Any additional procedures performed, such as removal of surrounding tissue
• Placement of a drain, if applicable
• Method of wound closure
• Any complications or unexpected findings
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 42330, ensure that the procedure meets the criteria for an uncomplicated intraoral sialolithotomy. It is important to use the appropriate code based on the specific salivary gland involved (submandibular, sublingual, or parotid). If the procedure is complicated or involves a different approach, other codes should be used. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 42330 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A physician performs an uncomplicated intraoral sialolithotomy to remove a stone from the submandibular salivary gland.
2. A patient presents with a stone in the sublingual salivary gland, and a physician performs an uncomplicated intraoral sialolithotomy to remove it.
3. A physician performs an uncomplicated intraoral sialolithotomy to remove a stone from the parotid salivary gland.
4. A patient requires the surgical removal of a stone from the submandibular salivary gland, and a physician performs an uncomplicated intraoral sialolithotomy.
5. A stone is identified in the sublingual salivary gland, and a physician performs an uncomplicated intraoral sialolithotomy to remove it.
6. A physician performs an uncomplicated intraoral sialolithotomy to remove a stone from the parotid salivary gland.
7. A patient presents with a stone in the submandibular salivary gland, and a physician performs an uncomplicated intraoral sialolithotomy to remove it.
8. A physician performs an uncomplicated intraoral sialolithotomy to remove a stone from the sublingual salivary gland.
9. A stone is identified in the parotid salivary gland, and a physician performs an uncomplicated intraoral sialolithotomy to remove it.
10. A patient requires the surgical removal of a stone from the submandibular salivary gland, and a physician performs an uncomplicated intraoral sialolithotomy.