How To Use CPT Code 42415

CPT 42415 describes the excision of the lateral lobe of a parotid tumor or the parotid gland, with dissection and preservation of the facial nerve. 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 42415?

CPT 42415 is used to describe the surgical procedure of removing the lateral lobe of a parotid tumor or the parotid gland while preserving the facial nerve. This code is used when the provider makes an incision near the ear, identifies the facial nerve using a nerve stimulator, removes the affected tissue, and closes the incision.

2. Official Description

The official description of CPT code 42415 is: ‘Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve.’

3. Procedure

1. The provider prepares the patient for the procedure and administers anesthesia.
2. An incision is made near the ear, and it is extended horizontally to the neck.
3. The provider further dissects the skin and uses a nerve stimulator to identify the facial nerve.
4. The lateral lobe of the parotid gland or any neoplastic growth in the lateral lobe is identified and removed.
5. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision in layers.

4. Qualifying circumstances

CPT 42415 is performed when there is a parotid tumor or a condition in the parotid gland that requires the removal of the lateral lobe. The procedure must include the dissection and preservation of the facial nerve. The patient must be appropriately prepped and anesthetized for the surgery.

5. When to use CPT code 42415

CPT code 42415 should be used when the provider performs the excision of the lateral lobe of a parotid tumor or the parotid gland, with dissection and preservation of the facial nerve. It is important to accurately document the procedure and ensure that the necessary steps are followed to meet the requirements of this code.

6. Documentation requirements

To support a claim for CPT 42415, the provider must document the following information:

• Patient’s diagnosis and the need for the excision of the lateral lobe
• Details of the procedure, including the incision, dissection, removal of the affected tissue, and closure
• Use of a nerve stimulator to identify the facial nerve
• Confirmation of the preservation of the facial nerve
• Any complications or additional procedures performed
• Signature of the provider performing the surgery

7. Billing guidelines

When billing for CPT 42415, ensure that the procedure includes the excision of the lateral lobe of the parotid tumor or parotid gland, with dissection and preservation of the facial nerve. It is important to follow the specific guidelines provided by the payer and accurately code any additional procedures or complications that may have occurred during the surgery.

8. Historical information

CPT 42415 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 provider performs the excision of the lateral lobe of a parotid tumor, preserving the facial nerve, for a patient with a benign parotid tumor.
2. A surgeon removes the lateral lobe of the parotid gland, with dissection and preservation of the facial nerve, for a patient with a malignant parotid tumor.
3. A specialist performs the excision of the lateral lobe of a parotid tumor, preserving the facial nerve, for a patient with recurrent parotid gland tumors.
4. A surgeon removes the lateral lobe of the parotid gland, with dissection and preservation of the facial nerve, for a patient with a large parotid tumor causing facial nerve compression.
5. A provider performs the excision of the lateral lobe of a parotid tumor, preserving the facial nerve, for a patient with a parotid gland tumor causing pain and swelling.
6. A surgeon removes the lateral lobe of the parotid gland, with dissection and preservation of the facial nerve, for a patient with a parotid tumor suspicious for malignancy.
7. A specialist performs the excision of the lateral lobe of a parotid tumor, preserving the facial nerve, for a patient with a parotid gland tumor causing facial asymmetry.
8. A surgeon removes the lateral lobe of the parotid gland, with dissection and preservation of the facial nerve, for a patient with a parotid tumor causing difficulty in swallowing.
9. A provider performs the excision of the lateral lobe of a parotid tumor, preserving the facial nerve, for a patient with a parotid gland tumor causing facial weakness.
10. A surgeon removes the lateral lobe of the parotid gland, with dissection and preservation of the facial nerve, for a patient with a parotid tumor causing pain and difficulty in speaking.