Unless you know neck and ear anatomy really well, you could be leaving dollars on the table. If your ENT performs a facial tissue transfer (14040) and you report branchial cleft cyst excision (42810) instead, you’ll lose 10.82 relative value units—which is $368 of lost revenue.
See if your ENT vocabulary is up to par by examining the following operative report.
Code This Excision
Procedure: Excision of left preauricular first branchial cleft sinus tract in a previously operated field.
Pre-/postoperative diagnosis(es): Recurrent left preauricular first branchial cleft sinus tract.
Note: This procedure qualifies for modifier 22 because it is a revision surgery in a previously operated field.
Specimens sent to lab: Overlying skin plus the deep sinus tract.
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Indications for surgery: Recurrent left preauricular sinus tract.
Findings in surgery: Scarred preauricular areas from previous excision with no cutaneous fistula and no discernible sinus tract.
Procedure: … An incision was made with the #11 scalpel blade around the area that the parents had stated most recently drained. This area was over the tragal cartilage region. A portion of the tragal cartilage was transected as the deep plane of the excision. Then, dissection was carried inferiorly and superiorly plus anteriorly to remove this portion of the pretragal scar and deep tissue. The depth of the dissection was the parotid gland. It was apparent that there was a large amount of scar tissue at...
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