Parotidectomy
4241542410wRVU: 9.33 — Superficial parotidectomy without nerve dissection — rarely appropriate (9.33 wRVU)42420wRVU: 19.04 — Total parotidectomy with nerve preservation (19.04 wRVU)42425wRVU: 13.08 — Total parotidectomy with nerve sacrifice (13.08 wRVU)42426wRVU: 22.09 — Total parotidectomy with unilateral radical neck dissection — single code; do not also report separate neck dissection code (22.09 wRVU)
Parotid mass [benign / malignant]
Same
[Superficial / total] parotidectomy with facial nerve preservation, [right / left]
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal (no long-acting non-depolarizing paralytics after induction; short-acting agents at induction acceptable if fully reversed before nerve dissection begins; facial nerve monitoring required)
Patient presents with a [X] cm [right / left] parotid mass. [Fine needle aspiration consistent with pleomorphic adenoma / Warthin's tumor / mucoepidermoid carcinoma / inconclusive.] CT/MRI demonstrates a [superficial / deep lobe] mass. No facial nerve involvement on imaging. Facial nerve monitoring arranged. Risks including facial nerve injury (temporary or permanent), Frey's syndrome, seroma, and salivary fistula discussed. Consent obtained.
[X] cm [well-circumscribed / infiltrative] [superficial / deep lobe] mass identified. Facial nerve identified and [preserved / stimulated] throughout. [Tumor consistency: soft / firm / cystic.] Facial nerve branches: [all 5 branches identified and preserved].
The patient was positioned supine with the head turned to the contralateral side. Continuous facial nerve monitoring electrodes were placed ipsilaterally in the orbicularis oculi and orbicularis oris. Baseline responses confirmed. No long-acting non-depolarizing paralytic agents were used after induction.
A modified Blair incision was made in the preauricular crease, curving behind the earlobe and extending into the neck. The skin flap was elevated in the sub-SMAS plane (superficial to the parotid fascia) anteriorly. The sternocleidomastoid muscle was retracted posteriorly.
The main trunk of the facial nerve was identified using the tragal pointer (approximately 1 cm inferior and deep to its tip) and confirmed with the tympanomastoid suture and the posterior belly of the digastric muscle as additional landmarks. The nerve was stimulated and confirmed with the facial nerve monitor.
Dissection proceeded antegrade from the nerve trunk distally, identifying and preserving the temporal, zygomatic, buccal, and marginal mandibular branches. The parotid tissue anterior to the nerve was excised systematically. The Stensen duct was identified and [suture-ligated / managed as appropriate].
[The deep lobe was removed by retracting the nerve superiorly and dissecting the deep lobe from the parapharyngeal space.]
Hemostasis confirmed. A closed suction drain was placed. The skin flap was re-draped and closed in layers with deep interrupted 3-0 Vicryl and running 4-0 Monocryl subcuticular. A pressure dressing was applied. Patient tolerated the procedure well.
None
Parotid specimen with [orientation suture / ink marking] sent to pathology
Minimal to [X] mL
One [10-Fr] JP drain
Patient taken to PACU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Right / left] parotid mass, [pleomorphic adenoma / Warthin's tumor / mucoepidermoid carcinoma]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Superficial / total] parotidectomy with facial nerve preservation, [right / left]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal (no long-acting non-depolarizing paralytics after induction; facial nerve monitoring required)
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a *** cm [right / left] parotid mass on imaging consistent with a [superficial / deep lobe] location. FNA showed [pleomorphic adenoma / Warthin's / inconclusive]. No facial nerve involvement on CT/MRI. Continuous facial nerve monitoring arranged. Risks including facial nerve injury (temporary or permanent), Frey's syndrome, seroma, and salivary fistula were discussed. Informed consent obtained.
FINDINGS: *** cm [well-circumscribed / infiltrative] [superficial / deep lobe] mass identified. Facial nerve trunk identified using the tragal pointer, tympanomastoid suture, and posterior digastric belly; temporal, zygomatic, buccal, and marginal mandibular branches identified and preserved. Nerve stimulation confirmed with facial nerve monitor throughout. Stensen's duct identified and managed.
DESCRIPTION OF PROCEDURE:
Patient positioned supine with head turned contralateral. Continuous facial nerve monitoring electrodes placed ipsilaterally in orbicularis oculi and oris; baseline responses confirmed. No long-acting non-depolarizing paralytic agents used after induction. Modified Blair incision made in preauricular crease, curving behind the earlobe into the neck. Skin flap elevated in the sub-SMAS plane (superficial to parotid fascia). SCM retracted posteriorly. Main facial nerve trunk identified approximately 1 cm inferior and deep to the tragal pointer, confirmed with tympanomastoid suture and posterior digastric belly as additional landmarks; stimulated and confirmed with nerve monitor. Dissection proceeded antegrade from trunk distally, identifying and preserving the temporal, zygomatic, buccal, and marginal mandibular branches. Parotid tissue anterior to nerve excised systematically. Stensen's duct identified and managed. [Deep lobe removed by retracting nerve superiorly.] Hemostasis confirmed. Closed suction drain placed. Wound closed in layers with deep 3-0 Vicryl and subcuticular 4-0 Monocryl. Pressure dressing applied. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Parotid specimen with orientation marking to pathology
COMPLICATIONS: None
DRAINS: One 10-Fr JP drain
DISPOSITION: Patient taken to PACU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Total parotidectomy with nerve sacrifice
CPT 42425. For high-grade malignancy with perineural invasion. Document nerve branches sacrificed and immediate reconstruction performed — standard options are interposition cable grafting (great auricular or sural nerve) or hypoglossal-to-facial transfer when proximal stump unavailable. Cross-face grafting is a delayed/staged procedure and is not performed at the time of ablation.
Submandibular gland excision
CPT 42440. Different procedure through submandibular incision. Document lingual nerve and marginal mandibular nerve preservation, duct ligation.
Parotidectomy with neck dissection
For malignancy with lymph node involvement. Document level of neck dissection (I-V) and structures preserved.
Charting Tips
- {'Anesthesia note': 'no long-acting non-depolarizing paralytics after induction (short-acting agents at induction are acceptable if fully reversed before nerve dissection)'}
- Document facial nerve identification landmarks used (tragal pointer, tympanomastoid suture, posterior digastric belly)
- State branches identified and nerve stimulation responses — routine documentation of all four surgical branches (temporal, zygomatic, buccal, marginal mandibular) is appropriate; the cervical branch need not be formally identified in most cases
- Skin flap plane is sub-SMAS (facelift plane), not subplatysmal — the platysma does not extend over the parotid gland
- Stensen duct management should be documented; routine ligation is not required for superficial parotidectomy when the deep lobe is preserved
- Frey syndrome counseling should be in the consent/preop note
- Postoperative facial nerve function (House-Brackmann grade) should be documented in recovery
- {'If neck dissection planned with malignancy': 'consider 42426 (total parotidectomy + radical neck, single code) vs. separately coded parotidectomy + neck dissection — clarify with your coder based on extent of dissection'}
Billing Tips
- Bill 42415 for superficial parotidectomy with facial nerve identification and preservation (16.73 wRVU, 90-day global). This is the standard code and requires formal nerve dissection. Bill 42410 (9.33 wRVU) for superficial parotidectomy without formal nerve dissection (rarely appropriate).
- Bill 42420 for total parotidectomy with facial nerve preservation (19.04 wRVU, 90-day global). Bill 42425 for total parotidectomy with nerve sacrifice (13.08 wRVU). Note: nerve sacrifice is valued lower than preservation because the dissection work of identifying and preserving the nerve drives the RVUs.
- Bill 42426 (22.09 wRVU) for total parotidectomy with unilateral radical neck dissection performed together — this single code covers both the parotidectomy and radical neck dissection. Do not separately report a parotidectomy code plus a neck dissection code when 42426 applies.
- For selective or modified radical neck dissection without 42426: use 38724 (modified radical neck dissection, 23.35 wRVU) or 38720 (complete cervical lymphadenectomy, 21.40 wRVU). Use 38700 only for a limited suprahyoid (level I) lymphadenectomy — not appropriate for most parotid malignancy workups.
- Facial nerve monitoring: the operating surgeon cannot bill a separate CPT for monitoring they perform themselves (bundled). An independent neurophysiologist or monitoring service may separately bill 95940/95941 — clarify with your facility.
- 90-day global period: Frey syndrome monitoring, drain management, and wound checks are bundled. Botulinum toxin injection for established Frey syndrome at a later date is a separate billable procedure.
General coding reference. Verify with your institution’s billing department before submitting claims.