42415

🧬 CPT 42415 — Excision of Parotid Tumor or Parotid Gland; Lateral Lobe, With Dissection and Preservation of Facial Nerve

📋 Code Information

Field	Value
CPT Code	42415
Descriptor	Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve
Section	Salivary Gland and Duct Procedures (42300-42699)
Approach	Open surgical
Global Period	090 days (Major Surgical Package)
Global Breakdown	Pre-op: 9% | Intra-op: 81% | Post-op: 10%
Bilateral Indicator	0 (150% bilateral adjustment does not apply)
Assistant Surgeon	Indicator 2 (Payment restriction does not apply; assistant allowed)
Co-Surgeon	Indicator 1 (Co-surgeons allowed with medical necessity documentation)
Team Surgery	Indicator 0 (Team surgery not permitted)
Effective Date	1990 (approx.)
Status / Year	Active ✅ (2026 CMS PFS)

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📖 Clinical Description

CPT 42415 describes a superficial (lateral lobe) parotidectomy performed for benign or low-grade malignant tumors, chronic inflammation, or cysts located within the lateral lobe of the parotid gland. The defining hallmark of this procedure is the formal identification, mobilization, dissection, and skeletonization of the facial nerve (cranial nerve VII) and its terminal branch divisions, ensuring the integrity of the nerve is preserved while the overlying parotid tissue and lesion are excised.

Anatomical Context

The parotid gland is an inverted pyramidal-shaped paired salivary gland located in the preauricular region and retromandibular fossa.

• Lateral (Superficial) Lobe: Represents approximately 80% of the gland volume and lies superficial to the plane of the facial nerve, overlying the masseter muscle and ascending ramus of the mandible.
• Medial (Deep) Lobe: Lies medial and deep to the facial nerve, extending toward the stylomandibular tunnel and parapharyngeal space.
• Facial Nerve (CN VII) Pathway: The main trunk exits the skull base through the stylomastoid foramen, enters the posteromedial surface of the parotid gland, and bifurcates at the pes anserinus into two primary divisions (temporofacial and cervicofacial) before branching into five terminal branches:
  1. Temporal (frontal) branch
  2. Zygomatic branch
  3. Buccal branch
  4. Marginal mandibular branch
  5. Cervical branch

Key Surgical Steps

1. Incision & Flap Elevation: A modified Blair incision (preauricular crease curving beneath the lobule and extending into an upper cervical skin crease) is made. A superficial musculoaponeurotic system (SMAS) / skin flap is elevated anteriorly over the parotid fascia.
2. Identification of Main Nerve Trunk: The main trunk of CN VII is localized using standard surgical landmarks:
   • The cartilaginous tragal pointer (nerve typically exits ~1.0–1.5 cm deep and inferior).
   • The posterior belly of the digastric muscle (nerve lies immediately superior).
   • The tympanomastoid suture line.
   • The styloid process.
3. Branch Dissection & Nerve Sparing: Antegrade dissection is performed along the nerve trunk, splitting the parotid tissue directly off the branching divisions. Each branch is carefully skeletonized and gently mobilized away from the tumor capsule.
4. Lobe & Tumor Resection: The lateral lobe containing the neoplasm is excised en bloc with a margin of healthy parotid tissue, keeping the tumor capsule intact to prevent tumor spillage (crucial for pleomorphic adenoma recurrence prevention).
5. Hemostasis, Drainage & Closure: Hemostasis is achieved using bipolar electrocautery and fine ligatures. A closed suction drain is placed via a counter-incision, and the wound is closed in anatomical layers.

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🔍 Clinical Indications & Medical Necessity

• Benign parotid neoplasms (e.g., pleomorphic adenoma, Warthin tumor/cystadenolymphoma, oncocytoma) residing in the superficial lobe.
• Malignant parotid neoplasms (e.g., low-grade mucoepidermoid carcinoma, acinic cell carcinoma) confined to the lateral lobe without direct invasion into CN VII.
• Carcinoma in situ or localized salivary gland neoplasms (D00.02, C07).
• Chronic recurrent sialadenitis / parotitis resistant to conservative medical therapy or sialendoscopy (K11.22, K11.23).
• Intraglandular sialolithiasis with associated chronic glandular damage or strictures (K11.5).
• Benign lymphoepithelial cysts or chronic salivary fistulas (K11.4).

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🔍 Includes vs. Excludes

Includes (Bundled Services)

• Complete surgical excision of the lateral (superficial) lobe of the parotid gland.
• Formal identification, neurolysis, branch tracing, and surgical preservation of CN VII and its branches.
• Operating surgeon-performed intraoperative facial nerve stimulation / monitoring.
• Exploration of parotid bed, local hemostasis, and placement of closed suction drains.
• Layered plastic/cosmetic closure of the surgical defect.
• Routine pre-operative workup and 90 days of normal post-operative care.

Excludes & Differentiating Codes

Code	Descriptor	Key Clinical Distinction
42410	Lateral lobe, without nerve dissection	Minimal nerve identification only; no formal branch dissection
42415	Lateral lobe, with dissection and preservation of facial nerve	Superficial lobectomy with formal CN VII branch skeletonization (This Code)
42420	Total parotidectomy, with nerve preservation	Complete gland resection (superficial AND deep lobes) with CN VII preservation
42425	Total parotidectomy, en bloc with nerve sacrifice	Complete gland resection with intentional sacrifice of CN VII (malignancy)
42426	Total parotidectomy, with nerve sacrifice and nerve graft	Total parotidectomy with CN VII sacrifice + immediate autologous/allograft nerve grafting
38720	Cervical lymphadenectomy (complete neck dissection)	Standalone neck dissection; may be separately reported if supported
38724	Cervical lymphadenectomy (modified radical neck dissection)	Selective/modified neck dissection; reported separately with modifier -59/-X{EPSU}
42400	Biopsy of salivary gland, needle	Diagnostic needle aspiration/core biopsy
42405	Biopsy of salivary gland, incisional	Diagnostic open wedge biopsy

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📊 Code Hierarchy

flowchart TD
    A["42300-42699 Salivary Gland and Duct Procedures"] --> B["Biopsy Procedures (42400-42405)"]
    A --> C["Excision Procedures — Parotid Gland"]
    
    C --> D["42410 Lateral lobe, WITHOUT nerve dissection"]
    C --> E["42415 Lateral lobe, WITH nerve dissection and preservation"]
    C --> F["42420 Total parotidectomy, WITH nerve preservation"]
    C --> G["42425 Total parotidectomy, en bloc WITH nerve sacrifice"]
    C --> H["42426 Total parotidectomy, WITH nerve sacrifice & nerve graft"]
    
    A --> I["Excision Procedures — Other Salivary Glands"]
    I --> J["42440 Submandibular gland excision"]
    I --> K["42450 Sublingual gland excision"]

    style E fill:#2B6CB0,stroke:#1A365D,stroke-width:2px,color:white

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💰 2026 CMS Reimbursement & RVU Breakdown

Under the 2026 Medicare Physician Fee Schedule (PFS PPR RVU 2026):

RVU / Payment Component	Facility Value	Non-Facility Value	Regulatory Notes
Work RVU (wRVU)	16.73	16.73	Physician intra-service work value
Practice Expense (PE) RVU	8.31	NA	Facility overhead expense
Malpractice (MP) RVU	2.51	2.51	Professional liability component
Total RVU	27.55	NA	Standard facility total RVU
2026 Conversion Factor (CF)	$33.4009	$33.4009	2026 Medicare non-QPP base conversion factor
Estimated National Medicare Base	~$920.19	NA	Geographic GPCI formula adjustments apply

2026 Fee Schedule Note

CMS payment calculations reflect the 2026 Medicare Physician Fee Schedule Final Rule baseline. Payment amounts vary locally based on geographic practice cost indices (GPCIs).

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🔄 Modifiers and Billing Guidelines

Common Modifiers for CPT 42415

Modifier	Description	Practical Application & Guidelines
-LT / -RT	Left / Right Laterality	Report to establish the anatomic side of the excised parotid gland.
-22	Increased Procedural Services	Used when operative work is significantly greater than typical (e.g., severe scarring from prior surgery/radiation, extensive inflammatory adhesions around nerve branches). Requires detailed documentation and rationale (>50% additional time/complexity).
-50	Bilateral Procedure	CMS Bilateral Indicator 0: The 150% bilateral payment adjustment does not apply. If bilateral lateral parotidectomies are performed, bill two separate line items with -RT and -LT modifiers.
-51	Multiple Procedures	Append to secondary surgical procedures performed in the same session (e.g., neck dissection 38724).
-52	Reduced Services	Append if lateral lobectomy is partially reduced at physician discretion.
-53	Discontinued Procedure	Append if procedure is aborted due to patient instability or extenuating circumstances after anesthesia induction.
-58	Staged / Related Procedure	Append if a planned re-excision or second-stage procedure is performed during the 90-day global period.
-59 / -X{EPSU}	Distinct Procedural Service	Used to unbundle independent, non-overlapping surgical procedures performed in a distinct anatomical area during the same operative session.
-78	Unplanned Return to OR	Append when returning to the operating room for complications during the 90-day global period (e.g., postoperative hematoma evacuation billed with code 35800-78).
-79	Unrelated Procedure in Global	Append for unrelated surgical procedures performed by the same surgeon during the 90-day global period.
-80 / -82 / -AS	Assistant at Surgery	Assistant Indicator 2: Assistant surgeon is payable with medical necessity documentation. Report -80 (MD/DO), -82 (resident unavailable), or -AS (PA/NP).
-62	Two Surgeons (Co-Surgery)	Co-Surgeon Indicator 1: Allowed when two distinct surgical specialists (e.g., Otolaryngologist and Microvascular Reconstructive Surgeon) act as co-surgeons; individual operative reports detailing distinct roles required.

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⚡ Intraoperative Neurophysiology Monitoring (IONM) Rules

• Surgeon-Performed Monitoring: When the primary surgeon operates the nerve stimulator or monitors facial nerve action potentials, the service is integral to CPT 42415 and is bundled (cannot be billed separately).
• Independent Monitoring Professional (Neurologist / PhD Neurophysiologist):
  • In-Person Attendance in OR: May bill add-on code +95940 (Continuous intraoperative neurophysiology monitoring in the OR, per 15 min) in conjunction with primary baseline testing codes (e.g., 95867-95868 or 95925-95937).
  • Remote / Outside the OR (Medicare Policy): Under CMS rules, monitoring from outside the OR must be billed with HCPCS code G0453 (Intraoperative neurophysiology monitoring from outside the OR, per patient, per 15 minutes), capped at allowable concurrent cases.

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📋 Critical Documentation Elements

To defend against post-payment audits, payer downcoding, or bundling denials:

1. Laterality & Anatomic Site: Explicitly specify the left or right parotid gland.
2. Superficial / Lateral Resection: Clearly document that the lateral (superficial) lobe was removed, distinguishing it from total parotidectomy.
3. Facial Nerve Dissection & Preservation: Operative report must contain explicit prose confirming:
   • Identification of the main trunk of cranial nerve VII (e.g., via tragal pointer, digastric muscle).
   • Antegrade/retrograde dissection and skeletonization of facial nerve branches.
   • Confirmation that the nerve remained structurally and functionally intact at the conclusion of the resection.
4. Pathology Correlation: Align operative findings with histopathology for precise ICD-10-CM diagnosis assignment.
5. Wound Closure & Drains: Document layered anatomical closure and placement of suction drains.

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📊 ICD-10-CM & HCC Risk Adjustment Crosswalk

Common Primary Diagnoses

ICD-10-CM Code	Description	CMS-HCC V24	CMS-HCC V28 (2026)
C07	Malignant neoplasm of parotid gland	HCC 10	HCC 21
D11.0	Benign neoplasm of parotid gland	Non-HCC	Non-HCC
D11.7	Benign neoplasm of other major salivary glands	Non-HCC	Non-HCC
D11.9	Benign neoplasm of major salivary gland, unspecified	Non-HCC	Non-HCC
D00.02	Carcinoma in situ of parotid gland	Non-HCC	Non-HCC
K11.20	Sialoadenitis, unspecified	Non-HCC	Non-HCC
K11.22	Chronic sialoadenitis	Non-HCC	Non-HCC
K11.23	Parotitis	Non-HCC	Non-HCC
K11.5	Sialolithiasis	Non-HCC	Non-HCC
K11.4	Fistula of salivary gland	Non-HCC	Non-HCC
R22.1	Localized swelling, mass and lump, neck	Non-HCC	Non-HCC
Z85.819	Personal history of malignant neoplasm of oral cavity and pharynx	Non-HCC	Non-HCC

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🏥 Facility & Inpatient Coding (MS-DRG & ICD-10-PCS)

MS-DRG Grouper (MDC 03 — Diseases & Disorders of Ear, Nose, Mouth & Throat)

When reported in the hospital inpatient setting, surgical procedures on the parotid gland group as follows:

MS-DRG	Description	Relative Weight (Approx.)
139	Salivary Gland Procedures	~1.35
146	Ear, Nose, Mouth & Throat Malignancy with MCC	~2.55
147	Ear, Nose, Mouth & Throat Malignancy with CC	~1.50
148	Ear, Nose, Mouth & Throat Malignancy without CC/MCC	~1.05

ICD-10-PCS Procedure Codes

In ICD-10-PCS, lateral (partial) parotidectomy is classified under root operation Excision (B), whereas total parotidectomy is classified under root operation Resection (T):

Procedure	PCS Code	Description
Right Lateral Parotidectomy (Partial)	0GB30ZZ	Excision of Right Parotid Gland, Open Approach
Left Lateral Parotidectomy (Partial)	0GB40ZZ	Excision of Left Parotid Gland, Open Approach
Bilateral Lateral Parotidectomy (Partial)	0GB50ZZ	Excision of Bilateral Parotid Glands, Open Approach
Total Parotidectomy, Right (Reference)	0GTC0ZZ	Resection of Right Parotid Gland, Open Approach
Total Parotidectomy, Left (Reference)	0GTD0ZZ	Resection of Left Parotid Gland, Open Approach

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📝 Practical Coding Scenarios

Scenario 1: Superficial Parotidectomy for Pleomorphic Adenoma

• History: A 48-year-old male presents with an enlarging, painless 3.0 cm mass in the right superficial parotid gland. Through a modified Blair incision, the main trunk of the facial nerve was identified using the tragal pointer. The individual branches (temporal, zygomatic, buccal, marginal mandibular, and cervical) were dissected and preserved intact. The lateral lobe and tumor were resected en bloc. Pathology confirms benign pleomorphic adenoma.
• Coding:
  • CPT: 42415-RT
  • ICD-10-CM: D11.0

Scenario 2: Lateral Parotidectomy with Selective Neck Dissection

• History: A 64-year-old female presents with biopsy-proven mucoepidermoid carcinoma of the left lateral parotid gland. The surgeon performs a left superficial parotidectomy with facial nerve dissection and preservation, followed by a selective neck dissection (Levels I–III).
• Coding:
  • CPT Primary: 42415-LT
  • CPT Secondary: 38724-59-LT (or 38724-XS-LT)
  • ICD-10-CM: C07

Scenario 3: Return to OR for Post-Operative Hematoma Evacuation

• History: On post-operative day 1 following a right lateral parotidectomy, the patient develops an expanding wound hematoma causing tension on the flap. The surgeon returns the patient to the OR for reopening of the incision, evacuation of the hematoma, and bipolar hemostasis of a bleeding vessel.
• Coding:
  • Primary Initial Procedure: 42415-RT (performed previously)
  • Return to OR Procedure: 35800-78-RT (Exploration for postoperative hemorrhage, neck)
  • ICD-10-CM: T81.0XXA (Hemorrhage and hematoma complicating a procedure)

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🔗 Related Specialty & CPT Codes

• 42410 — Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection
• 42420 — Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve
• 42425 — Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve
• 42426 — Excision of parotid tumor or parotid gland; total, with sacrifice of facial nerve and nerve graft
• 38720 — Cervical lymphadenectomy (complete neck dissection)
• 38724 — Cervical lymphadenectomy (modified radical neck dissection)
• 35800 — Exploration for postoperative hemorrhage, neck
• 95940 / G0453 — Intraoperative neurophysiology monitoring

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📚 References & Regulatory Citations

1. American Medical Association (AMA). CPT 2026 Professional Edition. Salivary Gland and Duct Guidelines.
2. Centers for Medicare & Medicaid Services (CMS). 2026 Medicare Physician Fee Schedule (PFS) Relative Value Files (PPR RVU 2026).
3. CMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services (2026), Chapter 8 (Digestive System).
4. AHA Coding Clinic for ICD-10-CM/PCS, Root Operation Excision vs. Resection Guidelines.
5. American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). Clinical Practice Guideline: Parotidectomy and Facial Nerve Management.