How To Use CPT Code 42450

CPT 42450 describes the excision of the sublingual gland, which is the smallest salivary gland located under the floor of the mouth. 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 42450?

CPT 42450 is used to describe the surgical removal of the sublingual gland, which is the smallest salivary gland found on each side of the mouth beneath the floor of the mouth. This procedure involves making an incision underneath the tongue, elevating mucosal flaps, identifying the gland, and removing it using forceps. The incision is then closed with stitches.

2. Official Description

The official description of CPT code 42450 is the excision of the sublingual gland. There are no additional notes or modifiers associated with this code.

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. A sharp incision is made underneath the tongue, on the inside of the lower teeth, over the diseased sublingual gland.
3. Mucosal flaps are elevated to expose the gland.
4. The gland is identified and freed from nearby tissues.
5. Forceps are used to grasp and remove the gland.
6. The incision is closed with stitches.

4. Qualifying circumstances

CPT 42450 is performed when there is a need to remove the sublingual gland due to disease or other conditions. The patient must have a diseased sublingual gland that requires excision. The procedure is typically performed by a qualified healthcare professional who is trained in surgical techniques.

5. When to use CPT code 42450

CPT code 42450 should be used when a patient requires the surgical removal of the sublingual gland. It is important to ensure that the procedure is medically necessary and that other treatment options have been considered and deemed ineffective or inappropriate. This code should not be used for any other salivary glands or ducts.

6. Documentation requirements

To support a claim for CPT 42450, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for sublingual gland excision
• Details of the procedure, including the incision site and technique used
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 42450, ensure that the procedure is accurately documented and coded. It is important to follow the specific guidelines provided by the payer and use the appropriate modifiers if necessary. CPT code 42450 should not be reported with other codes unless there are separate and distinct procedures performed during the same session.

8. Historical information

CPT 42450 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 patient undergoes the excision of the sublingual gland due to a tumor.
2. A healthcare professional performs the surgical removal of the sublingual gland to treat recurrent infections.
3. A patient with a chronic inflammatory condition requires the excision of the sublingual gland for symptom relief.
4. A healthcare professional performs the excision of the sublingual gland as part of a larger surgical procedure in the oral cavity.
5. A patient with a salivary stone in the sublingual gland undergoes the excision of the gland to alleviate symptoms.
6. A healthcare professional performs the excision of the sublingual gland to investigate and diagnose a suspected malignancy.
7. A patient with a sublingual gland abscess requires surgical intervention for drainage and removal of the gland.
8. A healthcare professional performs the excision of the sublingual gland to treat a chronic inflammatory condition that is unresponsive to conservative management.
9. A patient with recurrent sublingual gland infections undergoes the excision of the gland to prevent further complications.
10. A healthcare professional performs the excision of the sublingual gland as part of a reconstructive procedure in the oral cavity.