How To Use CPT Code 42335

CPT 42335 describes the procedure known as sialolithotomy, which involves the removal of a stone from the salivary gland. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 42335?

CPT 42335 is used to describe the surgical procedure of sialolithotomy, which involves the removal of a stone from the salivary gland. This code is used when a healthcare provider makes an intraoral incision and identifies the stone near the duct papilla or gland hilum. The stone is then removed using a grasping device, and topical antibiotics are applied. The incision is typically left open for healing.

2. Official Description

The official description of CPT code 42335 is: ‘Sialolithotomy; submandibular (submaxillary), complicated, intraoral.’

3. Procedure

1. After administering anesthesia, the healthcare provider makes an intraoral incision using a blade or CO2 laser.
2. The provider identifies the stone, which is usually located near the duct papilla or gland hilum.
3. A grasping device, such as Mosquito forceps, is used to remove the stone.
4. Topical antibiotics are applied to prevent infection.
5. The incision is typically left open for healing.

4. Qualifying circumstances

CPT 42335 is used for submandibular (submaxillary) sialolithotomy procedures that are complicated and performed intraorally. This code is specifically for cases where the stone is located near the duct papilla or gland hilum. It is important to note that there are separate codes for uncomplicated intraoral submandibular/submaxillary, sublingual, or parotid sialolithotomy procedures (CPT 42330) and extraoral or complicated intraoral parotid sialolithotomy procedures (CPT 42340).

5. When to use CPT code 42335

CPT code 42335 should be used when a healthcare provider performs a complicated intraoral submandibular (submaxillary) sialolithotomy procedure. This code is not appropriate for other types of sialolithotomy procedures or for uncomplicated cases. It is important to accurately document the complexity and location of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 42335, the healthcare provider must document the following information:

• Details of the patient’s condition and the need for sialolithotomy
• Description of the intraoral incision and identification of the stone
• Method used to remove the stone, such as a grasping device
• Application of topical antibiotics
• Details of the incision closure or leaving it open for healing
• Any additional relevant information or complications encountered during the procedure

7. Billing guidelines

When billing for CPT 42335, ensure that the procedure meets the criteria for a complicated intraoral submandibular (submaxillary) sialolithotomy. It is important to accurately document the complexity and location of the procedure to support the use of this code. Additionally, be aware of other codes available for different types of sialolithotomy procedures. If the provider uses an endoscope to locate the stones in a separate session, it may be possible to report the endoscopy and office visit separately, depending on documentation and coding rules.

8. Historical information

CPT 42335 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 healthcare provider performs a complicated intraoral submandibular sialolithotomy to remove a stone from a patient’s salivary gland.
2. During the procedure, the provider makes an intraoral incision, identifies the stone near the duct papilla, and successfully removes it using a grasping device.
3. Topical antibiotics are applied, and the incision is left open for healing.
4. The patient recovers well without any complications.
5. Another healthcare provider performs a similar procedure on a different patient, but encounters complications during the removal of the stone.
6. Despite the complications, the provider successfully removes the stone and applies topical antibiotics.
7. The incision is left open for healing, and the patient is closely monitored for any further issues.
8. Both cases meet the criteria for a complicated intraoral submandibular sialolithotomy and can be billed using CPT code 42335.
9. It is important to accurately document the details of the procedures to support the use of this code.
10. Each case is unique and requires careful consideration of the patient’s condition and the complexity of the procedure.