© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 42815 involves the excision of a branchial cleft cyst, vestige, or fistula that extends beneath the subcutaneous tissues and/or into the pharynx. A branchial cleft cyst, vestige, or fistula is a congenital anomaly that occurs in the lateral part of the neck due to the failure of the branchial cleft to close properly during embryonic development. This condition can lead to the formation of cysts or fistulas that may cause discomfort or complications if not addressed. The excision process requires careful surgical intervention, as the cyst or fistula may be located in a complex anatomical area, necessitating precise dissection to ensure complete removal. The procedure may involve horizontal incisions in the skin to access the cyst or fistula, and in cases where the anomaly extends into deeper tissues or the pharynx, additional techniques may be employed to ensure thorough excision. This may include using a peroral route for access or a combined approach for fistulas that extend from the neck into the pharynx, highlighting the intricacies involved in managing this congenital condition.
© Copyright 2025 Coding Ahead. All rights reserved.
The excision of a branchial cleft cyst, vestige, or fistula is indicated for the following conditions:
The procedure for excising a branchial cleft cyst, vestige, or fistula involves several detailed steps:
Post-procedure care involves monitoring the surgical site for signs of infection and ensuring proper healing. Patients may be advised to follow specific wound care instructions and to avoid activities that could strain the surgical area. Follow-up appointments are typically scheduled to assess recovery and address any complications that may arise. Pain management may also be provided as needed to ensure patient comfort during the recovery process.
| Short Descr | EXCISION OF NECK CYST | Medium Descr | EXC BRANCHIAL CLEFT CYST BELOW SUBQ TISS&/PHRYNX | Long Descr | Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx | 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) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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). | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.