Parotidectomy
42410
-
42415— Partial parotidectomy -
42420— Total parotidectomy without nerve sacrifice -
42425— Total parotidectomy with nerve sacrifice
Parotid mass [benign / malignant]
Same
[Superficial / total] parotidectomy with facial nerve preservation, [right / left]
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal
Patient supine, head turned to contralateral side, shoulder roll. No paralytic agents (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 placed in the orbicularis oculi and orbicularis oris bilaterally. Baseline responses confirmed. 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 subplatysmal plane anteriorly.
The sternocleidomastoid muscle was retracted posteriorly. The tragal pointer was identified. The main trunk of the facial nerve was found [1 cm deep and inferior / at the classic location] to the tragal pointer. The nerve was stimulated and confirmed with the facial nerve monitor.
Dissection proceeded antegrade along the facial nerve, identifying and preserving all five branches (temporal, zygomatic, buccal, marginal mandibular, cervical). The parotid tissue anterior to the nerve was excised systematically in a retrograde-to-anterograde fashion. The Stensen's duct was identified, ligated with 2-0 silk, and divided.
[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 PARALYTICS; 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 at the tragal pointer; all five branches identified and preserved. Nerve stimulation confirmed with facial nerve monitor throughout. Stensen's duct identified and ligated.
DESCRIPTION OF PROCEDURE:
Patient positioned supine with head turned contralateral. Continuous facial nerve monitoring electrodes placed in orbicularis oculi and oris; baseline responses confirmed. No paralytic agents used. Modified Blair incision made in preauricular crease, curving behind the earlobe into the neck. Skin flap elevated in the subplatysmal plane. SCM retracted posteriorly. Main facial nerve trunk identified 1 cm deep and inferior to the tragal pointer; stimulated and confirmed. Dissection proceeded antegrade, identifying and preserving all five branches (temporal, zygomatic, buccal, marginal mandibular, cervical). Parotid tissue anterior to nerve excised systematically. Stensen's duct identified, ligated with 2-0 silk, and divided. [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 whether immediate reconstruction performed (cable graft or cross-face graft).
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
- NO PARALYTICS. Facial nerve monitoring is essential. Document that no paralytic agents were used.
- Document facial nerve identification method (tragal pointer, retrograde from peripheral branch)
- State all branches identified and stimulation responses
- Stensen's duct identification and ligation must be documented
- Frey's syndrome counseling should be in consent/preop note
- Postoperative facial nerve function assessment should be documented in recovery
Billing Tips
- Bill 42410 for superficial parotidectomy (9.33 wRVU, 90-day global). Use when the superficial lobe is removed with facial nerve preservation. This is the most common parotidectomy code.
- Bill 42415 for total parotidectomy with facial nerve preservation (16.73 wRVU). Bill 42420 for total parotidectomy with facial nerve sacrifice (19.04 wRVU). Document the reason for nerve sacrifice (malignant invasion, encasement).
- Facial nerve monitoring does not have a separate physician CPT. It is bundled into the parotidectomy code. Document monitoring performed, baseline EMG, and any intraoperative changes.
- Neck dissection performed at the same setting (for malignant parotid tumors) is separately billable: 38700 (suprahyoid dissection), 38720 (radical neck), or 38724 (modified radical neck) with modifier -51.
- 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.