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The procedure described by CPT® Code 42330 refers to a sialolithotomy, which is a surgical intervention aimed at removing a calculus, commonly known as a stone, from the salivary glands or ducts, specifically the submandibular (submaxillary), sublingual, or parotid glands. This procedure is classified as uncomplicated and is performed intraorally, meaning that it is conducted within the mouth. During the sialolithotomy, the surgeon identifies and protects the papilla of the salivary duct associated with the affected gland. An incision is made in the mucosa overlying the duct or gland to expose the area where the calculus is located. The surgeon then incises the salivary gland or duct to access the calculus, which is carefully dissected free from the surrounding tissue. After the calculus is removed, the duct or gland is repaired with sutures, and the overlying mucosa is also sutured closed. This procedure is distinct from more complicated sialolithotomies, which may involve more extensive dissection and additional challenges, such as multiple calculi or larger stones that are more difficult to access.
© Copyright 2025 Coding Ahead. All rights reserved.
The sialolithotomy procedure described by CPT® Code 42330 is indicated for the removal of a calculus from the submandibular (submaxillary), sublingual, or parotid salivary glands or ducts. This procedure is typically performed when a patient presents with symptoms related to salivary gland obstruction caused by a stone, which may include:
The sialolithotomy procedure involves several key steps to ensure the successful removal of the calculus. These steps include:
Post-procedure care following a sialolithotomy includes monitoring for any signs of complications, such as infection or excessive bleeding. Patients may be advised to maintain good oral hygiene to prevent infection and to follow any specific dietary recommendations provided by their healthcare provider. Recovery time can vary, but patients are generally expected to experience some swelling and discomfort in the area, which can be managed with prescribed pain relief. Follow-up appointments may be scheduled to assess healing and ensure that the salivary function is restored.
| Short Descr | REMOVAL OF SALIVARY STONE | Medium Descr | SIALOT SUBMNDBLR SUBLNGL/PRTD UNCOMP INTRAORAL | Long Descr | Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | LT | Left side (used to identify procedures performed on the left side of the body) | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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