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The CPT® Code 42810 refers to the excision of a branchial cleft cyst or vestige, specifically when it is confined to the skin and subcutaneous tissues. A branchial cleft cyst is a congenital anomaly that arises from the incomplete closure of the branchial cleft during embryonic development, typically manifesting as a cyst, vestige, or fistula located on the lateral aspect of the neck. In this procedure, the physician performs an excision, which involves making a series of horizontal incisions in the skin over the area where the branchial cyst or vestige is located. This approach allows for the exposure of the cyst or vestige, which often follows a complex, tortuous path beneath the skin and subcutaneous layers. The goal of the procedure is to completely remove the cyst or vestige while ensuring that all affected tissues are excised to prevent recurrence. It is important to note that this code is specifically for cases where the cyst or vestige does not extend beyond the skin and subcutaneous tissues, distinguishing it from more complex procedures that may involve deeper structures or the pharynx, as indicated by CPT® Code 42815.
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The procedure associated with CPT® Code 42810 is indicated for the excision of branchial cleft cysts, vestiges, or fistulas that are confined to the skin and subcutaneous tissues. These conditions typically arise due to congenital anomalies resulting from the failure of the branchial cleft to close during embryonic development. The presence of a branchial cleft cyst or vestige may lead to symptoms such as swelling or discomfort in the lateral neck area, prompting surgical intervention to prevent complications such as infection or recurrence.
The procedure for excising a branchial cleft cyst or vestige begins with the physician making a series of horizontal incisions in the skin over the cyst or vestige located on the lateral neck. This incision technique is crucial as it allows for adequate exposure of the underlying structures. Once the skin is incised, the physician carefully dissects the cyst or vestige from the surrounding subcutaneous tissue. It is important to note that the cyst or vestige may follow a tortuous path, requiring meticulous dissection to ensure complete removal. The physician takes care to excise the cyst in its entirety to minimize the risk of recurrence. The procedure is concluded by closing the incisions in the skin, ensuring proper healing and cosmetic appearance.
After the excision of a branchial cleft cyst or vestige, post-procedure care is essential for optimal recovery. Patients are typically monitored for any signs of infection or complications at the incision site. Pain management may be provided as needed, and patients are advised on wound care to ensure proper healing. Follow-up appointments may be scheduled to assess the healing process and to ensure that there are no signs of recurrence. It is important for patients to adhere to any specific instructions given by the physician regarding activity restrictions and care of the surgical site.
| Short Descr | EXCISION OF NECK CYST | Medium Descr | EXC BRANCHIAL CLEFT CYST CONFINED SKN&SUBQ TIS | Long Descr | Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply 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 |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | 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. | 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) | QS | Monitored anesthesia care service | QX | Crna service: with medical direction by a physician | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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