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The procedure described by CPT® Code 42408 involves the excision of a sublingual salivary cyst, commonly referred to as a ranula. A ranula is a type of mucocele that forms in the floor of the mouth, typically as a result of trauma to the sublingual gland or duct, obstruction of the duct, or infection of the gland. When the sublingual gland or duct is damaged, mucous can escape and accumulate in the surrounding soft tissues, leading to the formation of a cyst. The excision procedure aims to remove this cyst to alleviate symptoms and prevent further complications. During the procedure, Wharton's duct, which is the duct associated with the sublingual gland, is cannulated to ensure it is properly identified and protected throughout the surgical process. An incision is made directly over the cyst, and careful dissection is performed to separate the cyst from the surrounding tissues, including the sublingual salivary gland, submandibular duct, and lingual nerve, to minimize the risk of injury. Once the cyst is successfully excised, the surgical site is repaired in layers to promote proper healing.
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The excision of a sublingual salivary cyst (ranula) is indicated in the following situations:
The procedure for excising a sublingual salivary cyst involves several critical steps to ensure successful removal while minimizing damage to surrounding structures.
Post-procedure care following the excision of a sublingual salivary cyst typically includes monitoring for any signs of infection or complications. Patients may be advised to manage pain with prescribed analgesics and to maintain good oral hygiene to promote healing. Follow-up appointments may be scheduled to assess the surgical site and ensure proper recovery. Patients should be informed about potential signs of complications, such as increased swelling, persistent pain, or discharge from the surgical site, and instructed to seek medical attention if these occur.
| Short Descr | EXCISION OF SALIVARY CYST | Medium Descr | EXC SUBLINGUAL SALIVARY CYST RANULA | Long Descr | Excision of sublingual salivary cyst (ranula) | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 0 - 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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