How To Use CPT Code 42408

CPT 42408 describes the excision of a sublingual salivary cyst, also known as a ranula, which is located in the tissues beneath the tongue. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 42408?

CPT 42408 is used to describe the excision of a ranula, which is a large mucous cyst located in the tissues of the floor of the mouth below the tongue. This code is used when a healthcare provider surgically removes the ranula using a sharp incision and surgical instruments. The site of the excision is then sutured to promote healing.

2. Official Description

The official description of CPT code 42408 is: ‘Excision of sublingual salivary cyst (ranula).’ This code does not require any additional notes or modifiers.

3. Procedure

1. The healthcare provider accesses the ranula, which is located in the tissues beneath the tongue, through a sharp incision using a blade or scalpel.
2. The ranula is then carefully removed using surgical instruments.
3. After the excision, the site is sutured to promote healing.

4. Qualifying circumstances

CPT 42408 is appropriate when a patient presents with a sublingual salivary cyst, or ranula, that requires surgical excision. The cyst must be located in the tissues beneath the tongue. It is important to note that this code should not be used for the removal of a mucocele on the vestibular mucosa of the lip, as that would require a different code (40810).

5. When to use CPT code 42408

CPT code 42408 should be used when a healthcare provider performs the excision of a sublingual salivary cyst, or ranula, located in the tissues beneath the tongue. It is important to ensure that the cyst is in the appropriate location before using this code.

6. Documentation requirements

To support a claim for CPT 42408, the healthcare provider must document the following information:

• Patient’s diagnosis of a sublingual salivary cyst (ranula)
• Description of the procedure performed, including the incision and excision of the cyst
• Details of the closure, including the suturing of the excision site
• Any additional relevant information, such as complications or follow-up care

7. Billing guidelines

When billing for CPT 42408, ensure that the excision is performed on a sublingual salivary cyst, or ranula, located in the tissues beneath the tongue. There is no need to report a separate code for closure, as it is included in the excision code. It is important to accurately document the procedure and provide any necessary supporting documentation.

8. Historical information

CPT 42408 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A dentist performing the excision of a sublingual salivary cyst (ranula) located beneath the tongue.
2. An oral surgeon surgically removing a ranula from the floor of the mouth using a sharp incision and suturing the excision site.
3. A maxillofacial surgeon excising a sublingual salivary cyst (ranula) and providing post-operative care to ensure proper healing.
4. A head and neck surgeon performing the excision of a ranula and documenting the procedure for accurate billing and medical record keeping.
5. An otolaryngologist surgically removing a sublingual salivary cyst (ranula) and providing instructions for post-operative care to the patient.
6. A healthcare provider excising a ranula and discussing the procedure and potential risks with the patient before obtaining informed consent.
7. A dental surgeon performing the excision of a sublingual salivary cyst (ranula) and providing pain management during and after the procedure.
8. An oral and maxillofacial surgeon removing a ranula and documenting the details of the excision for accurate billing and medical record keeping.
9. A healthcare provider excising a sublingual salivary cyst (ranula) and providing post-operative instructions to the patient for proper healing.
10. An oral surgeon performing the excision of a ranula and collaborating with other healthcare professionals to ensure comprehensive care for the patient.