42415

😷 CPT Code 42415 - Parotidectomy; Lateral Lobe with Identification/Preservation of Facial Nerve

Code Description

CPT 42415 - Parotidectomy; lateral lobe with identification/preservation of facial nerve

This code represents a surgical procedure involving the removal of the lateral (superficial) lobe of the parotid gland with careful identification and preservation of the facial nerve (cranial nerve VII).

Code Tree/Hierarchy

CPT Code Structure
└── Surgery (10000-69999)
    └── Digestive System (40000-49999)
        └── Salivary Gland Procedures (42400-42699)
            └── Parotid Gland Procedures (42400-42451)
                ├── 42400 - Biopsy of parotid gland
                ├── 42405 - Parotid duct ligation
                ├── 42408 - Drainage of parotid abscess; external
                ├── 42409 - Drainage of parotid abscess; intraoral
                ├── 42410 - Parotidectomy; removal of parotid tumor
                ├── 42415 - Parotidectomy; lateral lobe with identification/preservation of facial nerve
                ├── 42420 - Parotidectomy; total, with preservation of facial nerve
                ├── 42425 - Parotidectomy; total, with sacrifice of facial nerve
                ├── 42426 - Parotidectomy; total, with sacrifice of facial nerve, with nerve graft
                └── 42430-42451 - Other parotid procedures

Common Diagnoses for 42415

ICD-10-CM Code	Description
C07	Malignant neoplasm of parotid gland
D11.0	Benign neoplasm of parotid gland
K11.1	Hypertrophy of salivary gland
K11.2	Sialadenitis (parotitis)
K11.4	Fistula of salivary gland
K11.5	Sialolithiasis (parotid)
K11.7	Disturbance of salivary secretion
K11.8	Other diseases of salivary glands
K11.9	Disease of salivary gland, unspecified
D00.02	Carcinoma in situ of parotid gland
C79.89	Secondary malignant neoplasm of other specified sites (metastatic to parotid)

External Cause Codes (if applicable)

ICD-10-CM Code	Description
Y92.531	Dentist office (place of occurrence)
Y92.239	Hospital (place of occurrence)
Y92.009	Private residence (place of occurrence)
Y99.0	Civilian activity done for income or pay (work-related)
Y99.8	Leisure activity

Includes

Lateral (superficial) parotidectomy - removal of the superficial lobe only
Facial nerve identification - nerve must be identified and visualized
Facial nerve preservation - nerve integrity maintained throughout procedure
Tumor excision within the lateral lobe
Dissection of facial nerve branches (temporal, zygomatic, buccal, marginal mandibular, cervical)
Hemostasis and wound closure
Placement of drain (if performed)

Excludes

Code	Description	Reason
42400	Biopsy of parotid gland	Less extensive procedure
42410	Parotidectomy; removal of parotid tumor	Does not specify nerve preservation
42420	Parotidectomy; total, with preservation of facial nerve	More extensive (total vs. lateral)
42425	Parotidectomy; total, with sacrifice of facial nerve	Nerve sacrificed, not preserved
42426	Parotidectomy; total with nerve graft	Includes nerve graft
42430	Excision of lesion of parotid duct	Different anatomical structure
42440	Parotid duct ligation	Different procedure
42505-42509	Sialendoscopy	Endoscopic approach
42690	Sialogogogue stimulation	Non-surgical

Assistant Surgeon Information

Payer Type	Assistant Payable	Typical Reimbursement
Medicare	Yes (80, 81, 82)	16% of surgeon fee
Commercial	Varies by contract	10-20% of surgeon fee
Medicaid	Varies by state	10-16% of surgeon fee

Modifiers for Assistant Surgeon:

-80 - Assistant surgeon
-81 - Minimum assistant surgeon
-82 - Assistant surgeon (when qualified resident not available)
-AS - Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

Work RVU Breakdown (2025 Medicare Physician Fee Schedule)

Component	RVU Value	Description
Work RVU	14.52	Physician work effort
Practice Expense RVU	5.89	Facility/equipment costs
Malpractice RVU	2.18	Liability insurance costs
Total RVU (Non-Facility)	22.59	Office-based setting
Total RVU (Facility)	20.41	Hospital/ASC setting

Note: RVU values may vary by geographic location due to GPCI adjustments

MS-DRG Information (Inpatient Procedures)

When performed in an inpatient setting, 42415 may map to the following MS-DRGs:

MS-DRG	Description	Relative Weight (Approx.)
063	Head & Neck Malignancy with Major OR Procedure	2.85
064	Head & Neck Malignancy without Major OR Procedure	1.42
065	Salivary Gland Procedures	1.68
689	Kidney & Urinary Tract Infections with MCC	1.25

CC/MCC Considerations:

MCC (Major Complication/Comorbidity): Sepsis, respiratory failure, acute kidney injury
CC (Complication/Comorbidity): Diabetes with complications, malnutrition, anemia

Global Period

Period	Days	Services Included
Pre-operative	1 day	Day before surgery
Intra-operative	0 days	Day of surgery
Post-operative	90 days	90 days following surgery
Total Global	90 days	All related E/M services included

Services NOT included in global period:

Treatment for unrelated conditions
Return to OR for complications (use modifier 78)
Decision for surgery (use modifier 57 if within global of another procedure)
Staged procedures (use modifier 58)

Modifiers

Modifier	Description	When to Use
50	Bilateral procedure	Not applicable (parotid is unilateral)
51	Multiple procedures	When additional distinct procedures performed
52	Reduced services	Procedure partially reduced
53	Discontinued procedure	Procedure stopped due to patient condition
57	Decision for surgery	E/M on day of surgery leading to decision
58	Staged procedure	Planned return to OR during global period
59	Distinct procedural service	Separate from other same-day procedures
62	Two surgeons	Two surgeons working as primary surgeons
76	Repeat procedure by same physician	Same procedure repeated
77	Repeat procedure by different physician	Same procedure by different surgeon
78	Return to OR for complication	Unplanned return during global period
79	Unrelated procedure during global	Different procedure during global period
80	Assistant surgeon	Assistant surgeon present
LT	Left side	Left parotid gland
RT	Right side	Right parotid gland

Coding Examples

Example 1: Benign Parotid Tumor

CPT: 42415-RT
ICD-10-CM: D11.0 (Benign neoplasm of parotid gland)
Description: Patient underwent right lateral parotidectomy with facial nerve 
preservation for benign pleomorphic adenoma. Facial nerve identified and 
preserved throughout procedure. Pathology confirmed benign tumor.

Example 2: Malignant Parotid Tumor

CPT: 42415-LT
ICD-10-CM: C07 (Malignant neoplasm of parotid gland)
Description: Patient underwent left lateral parotidectomy with facial nerve 
preservation for mucoepidermoid carcinoma. Nerve monitored throughout 
procedure. Margins clear on frozen section.

Example 3: Chronic Sialadenitis

CPT: 42415-RT
ICD-10-CM: K11.2 (Sialadenitis)
Description: Patient with recurrent parotitis underwent right lateral 
parotidectomy. Facial nerve identified and preserved. Chronic inflammatory 
changes noted on pathology.

Example 4: With Assistant Surgeon

CPT: 42415-RT-80
ICD-10-CM: D11.0
Assistant: 42415-RT-81 (or AS for PA/NP)
Description: Primary surgeon with assistant surgeon for complex dissection 
due to tumor size and location near facial nerve branches.

Example 5: Return to OR for Hematoma

CPT: 42415-RT (initial)
CPT: 42415-RT-78 (return to OR)
ICD-10-CM: D11.0, T81.0XXA (Hemorrhage following procedure)
Description: Patient returned to OR on post-op day 2 for evacuation of 
hematoma. Same procedure code with modifier 78.

Documentation Requirements

Operative Report Must Include:

Preoperative Diagnosis
Postoperative Diagnosis
Procedure Performed (clearly state lateral parotidectomy)
Side (left or right)
Facial Nerve Documentation
- Nerve identified (yes/no)
- Nerve preserved (yes/no)
- Nerve monitoring used (yes/no)
- Any nerve injury (document if occurred)
Tumor/Lesion Description
- Size
- Location within gland
- Relationship to facial nerve
Extent of Resection (lateral lobe only)
Closure Method
Drain Placement (if applicable)
Complications (if any)
Specimen Sent to Pathology

Key Phrases to Document:

“Lateral (superficial) parotidectomy performed”
“Facial nerve identified and preserved”
“All branches of facial nerve visualized”
“Tumor excised from lateral lobe”
“Hemostasis achieved”
“Wound closed in layers”

Medical Necessity

Indications for 42415:

Benign tumors (pleomorphic adenoma, Warthin tumor)
Malignant tumors (mucoepidermoid carcinoma, adenoid cystic carcinoma)
Chronic recurrent parotitis unresponsive to conservative treatment
Sialolithiasis with recurrent infection
Cysts of the parotid gland
Trauma to parotid gland requiring resection

Contraindications:

Medically unstable patient
Inability to tolerate general anesthesia
Metastatic disease where surgery would not provide benefit
Patient refusal

Common Denial Reasons

Denial Code	Reason	Resolution
CO-50	Medical necessity	Provide operative report and pathology
CO-97	Bundled service	Verify procedure not included in global
CO-16	Missing information	Submit complete operative report
CO-22	Billing/coding error	Verify correct code and modifiers
CO-109	Not covered by payer	Check patient benefits

Compliance Considerations

Nerve Preservation Must Be Documented - If nerve not preserved, code 42420 or 42425 may be more appropriate
Lateral vs. Total - Ensure documentation supports lateral lobe only (not total parotidectomy)
Bilateral Coding - Code separately for each side with modifiers LT/RT (not modifier 50)
Global Period Compliance - Do not bill E/M services during global period unless unrelated (modifier 24)
Assistant Surgeon - Verify payer allows assistant for this procedure
Pathology Correlation - Ensure pathology report supports medical necessity

CPT	Description	Relationship
42400	Parotid biopsy	May precede 42415
42410	Parotid tumor removal	Less specific than 42415
42420	Total parotidectomy with nerve preservation	More extensive
42425	Total parotidectomy with nerve sacrifice	More extensive
69990	Microsurgical techniques	May be added if microscope used
31575	Laryngoscopy with nerve monitoring	If nerve monitoring performed

Clinical Pearls

Facial Nerve Monitoring - Intraoperative nerve monitoring is commonly used but not separately billable
Frey Syndrome - Common complication (gustatory sweating); counsel patients preoperatively
Temporary Facial Weakness - Common postoperatively; usually resolves within weeks to months
Permanent Facial Nerve Injury - Rare when nerve preserved; risk increases with malignancy
Drain Placement - Often placed to prevent sialocele formation
Pressure Dressing - Applied postoperatively to prevent fluid collection

References

Current Procedural Terminology (CPT) 2025
Medicare Physician Fee Schedule 2025
ICD-10-CM Official Guidelines for Coding and Reporting
CMS National Coverage Determinations
American Academy of Otolaryngology-Head and Neck Surgery Guidelines

Quick Reference Card

┌─────────────────────────────────────────────────────────┐
│  CPT 42415 - Lateral Parotidectomy with Nerve Preserve │
├─────────────────────────────────────────────────────────┤
│  Global Period: 90 days                                 │
│  Assistant Allowed: Yes (80/81/82/AS)                   │
│  Bilateral: Code separately (LT/RT)                     │
│  wRVU: 14.52                                            │
│  Key Documentation: Nerve identified AND preserved      │
│  Common ICD-10: D11.0, C07, K11.2                       │
│  MS-DRG: 063, 065                                       │
└─────────────────────────────────────────────────────────┘

Last Updated: February 2026 Code Status: Active Next Review: January 2027

Explorer