How To Use CPT Code 42810

CPT 42810 describes the excision of a branchial cleft cyst or vestige that is confined to the skin and subcutaneous tissues. 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 42810?

CPT 42810 can be used to describe the surgical excision of a branchial cleft cyst or vestige that is limited to the skin and subcutaneous tissues. This procedure involves the removal of a congenital cystic swelling that arises from the lateral aspect of the neck. It is performed when the second branchial (pharyngeal) cleft fails to close during embryonic development.

2. Official Description

The official description of CPT code 42810 is: ‘Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues.’

3. Procedure

1. The physician performs surgical resection of the branchial cleft cyst or vestige using a sharp surgical blade.
2. The incision is confined to the skin and subcutaneous tissues only.
3. The procedure is usually performed under general anesthesia.
4. After excision, the physician performs simple closure of the incision.

4. Qualifying circumstances

Patients eligible for CPT 42810 are those with a branchial cleft cyst or vestige that is confined to the skin and subcutaneous tissues. This congenital cystic swelling arises from the lateral aspect of the neck when the second branchial (pharyngeal) cleft fails to close during embryonic development.

5. When to use CPT code 42810

CPT code 42810 should be used when a physician performs the excision of a branchial cleft cyst or vestige that is limited to the skin and subcutaneous tissues. It is important to ensure that the procedure is confined to these specific areas and does not extend beyond them.

6. Documentation requirements

To support a claim for CPT 42810, the physician must document the following information:

• Patient’s diagnosis of a branchial cleft cyst or vestige
• Description of the procedure performed, including the use of a sharp surgical blade
• Confirmation that the excision was confined to the skin and subcutaneous tissues
• Details of the closure technique used
• Any additional relevant information, such as the use of general anesthesia
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 42810, ensure that the excision is confined to the skin and subcutaneous tissues. It is important to accurately document the procedure and use the appropriate diagnosis code for a branchial cleft cyst or vestige. There are no specific guidelines regarding reporting CPT 42810 with other codes.

8. Historical information

CPT 42810 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 the excision of a branchial cleft cyst confined to the skin and subcutaneous tissues of a patient’s neck.
2. A surgeon removes a branchial cleft vestige that is limited to the skin and subcutaneous tissues of a patient’s neck.
3. A physician excises a branchial cleft cyst that is confined to the skin and subcutaneous tissues, ensuring no extension beyond these areas.
4. A surgeon performs the surgical resection of a branchial cleft vestige, confining the excision to the skin and subcutaneous tissues only.
5. A physician excises a branchial cleft cyst that is limited to the skin and subcutaneous tissues, using a sharp surgical blade.
6. A surgeon removes a branchial cleft vestige confined to the skin and subcutaneous tissues, performing simple closure after excision.
7. A physician performs the excision of a branchial cleft cyst that is confined to the skin and subcutaneous tissues, ensuring no extension beyond these areas.
8. A surgeon removes a branchial cleft vestige that is limited to the skin and subcutaneous tissues, using a sharp surgical blade.
9. A physician excises a branchial cleft cyst confined to the skin and subcutaneous tissues, performing simple closure after excision.
10. A surgeon performs the surgical resection of a branchial cleft vestige that is limited to the skin and subcutaneous tissues, ensuring no extension beyond these areas.