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Clinical Indicators: Neck Dissection

Clinical Indicators: Neck Dissection
Approach ProcedureCPTRBRVS Global Days
Suprahyoid38700090
Radical Neck Dissection (RND)
(lymphadenectomy)*
38720090
Modified RND38724090
*Note: Radical neck dissection performed in conjunction with removal of a primary malignancy is coded with the primary; in some instances a single CPT codes describes both, eg CPT 31365for total laryngectomy with radical neck dissection whereas in others, each must be coded separately.
  1. History (one or more required)
    1. Primary head and neck malignancy proven by biopsy or prior surgery (required).
    2. Enlarging or persisting neck mass with history of regional primary malignancy. (May require needle or open biopsy or imaging supportive of neoplasm.)
    3. Neck mass malignancy proven by biopsy or fine-needle aspiration but no primary site identified.
  2. Physical Examination (required)
    Comprehensive examination of the head and neck with emphasis
    on:

    1. Description of neck mass (Levels) and clinical staging (N0-N3, M0-M1, Staging I-V).
    2. Description of head and neck primary site and stage, if known.
  3.  Tests (required)
    1. Pathologic confirmation of primary site or in case of unknown primary, confirmation of neck mass malignancy.
    2. CT Scan, PET, ultrasound, or MRI of head and neck
    3. Metastatic work-up rule out distal metastasis before performing the Neck Dissection

Postoperative Observations

  1. Wound infection or breakdown.
  2. Bleeding.
  3. Facial edema
  4. Chylous leak.
  5. Function of VII, X, XI, XII cranial nerve, cervical sympathetic trunk, and brachial plexus.
  6. Electrolyte balance and blood volume determination.
  7. Adequate airway management and deglutition
  8. Drains–document if functional or removed.
  9. Pneumothorax.

Outcome Review

  1. One Week
    1. Review chart for topics listed above, under “postoperative observations.”
    2. Is patient able to return to normal daily activity? Assess need for physical therapy
    3. Recommendations made following review of pathological findings including need for adjuvant therapy. (Positive margins, extracapsular spread, perineural invasion, soft tissue invasion.
  2. Beyond One Month
    1. Tumor status–Any evidence for residual or recurrent tumor? This likely will include endoscopy and “re-staging” imaging post treatment.
    2. Functional assessment–Is patient able to return to work? Are there any restrictions? Assess need for physical therapy.
    3. Cancer registry—Is case being followed by local tumor registry, institution or surgeon for long-term survival studies?
    4. Long-term follow-up by surgical oncologist

Associated ICD-10-CM Diagnostic Codes (Representative, but not all-inclusive, codes)

  • C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
  • C79.89 Secondary malignant neoplasm of other specified sites
  • C79.9 Secondary malignant neoplasm of unspecified site
  • C80.0 Disseminated malignant neoplasm, unspecified
  • C80.1 Malignant (primary) neoplasm, unspecified
  • C45.9 Mesothelioma, unspecified
  • G73.1 Lambert-Eaton syndrome in neoplastic disease

Additional Information

Assistant Surgeon — Y

Patient Information

Neck dissection is performed in order to remove known or suspected lymph nodes containing cancer. Its purpose is to assess the extent of disease spread and aggressiveness (extranodal extension), to prevent regional disease progression with involvement of cranial nerves, skin and major vessels. Over the past 50 years it has proven to be an effective method of head and neck cancer control. Complications of this surgery include wound infection and breakdown, bleeding, leakage of lymph fluid, injury to nerves (controlling the lower face, throat, shoulder, tongue, diaphragm), and skin sensation under ear and jaw. Undesired effects can include shoulder weakness and chronic pain in the neck and shoulder. Most patients who have only a neck dissection are able to return to normal daily activities after healing.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.


© 2012 American Academy of Otolaryngology-Head and Neck Surgery. 1650 Diagonal Road Alexandria, VA 22314.

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