Clinical History: right neck mass
Gross Description: Received in formalin is 4 x 3 x 2.5cm parotid gland. The resection margin is inked blue. Cut sections show a well circumscribed 2 x 1.5 x 2.6cm mass with fleshy, light brown, solid appearance. There is yellow fluid coming out onto the surface which looks like pus. The mass is very close to the inked surgical margins. No stone identified. Representative sections submitted in cassettes A1-5.
Final Diagnosis: Right superficial parotid gland, excision: Warthin’s tumor, measuring 2 cm in greatest dimension. All surgical margins are free of tumor.
What is the correct CPT code?
Answer: C – 88307 – Salivary gland. The neck mass was determined to be a superficial parotid gland that was entirely excised.
What diagnosis codes are assigned?
Important facts: The differences from ICD-9 and ICD-10 is that in ICD-9 the diagnosis code was listed within the Tumor section of the alpha index, however in ICD-10, when you look up Tumor in the alpha index it refers the reader to the neoplasm table for the diagnosis code. It is a basic reminder that you should not code directly from the alpha index in either ICD-9 or ICD-10, you should confirm the codes in the Tabular list of the code book.
AMA CPT Professional Edition 2014
Optum ICD-9-CM for Physician Vol 1 & 2 2014
AAPC ICD-10-CM Draft 2014
This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of pathology. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.
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