CPT 42815 Brachial Cleft Cyst Excision Reimbursement | OpenPayer

Summary & Overview

CPT 42815: Brachial Cleft Cyst Excision

CPT code 42815 represents surgical excision of a brachial cleft cyst (vestige), a congenital lateral neck cyst arising from incomplete closure of the second branchial cleft. This procedure addresses symptomatic cysts that can cause swelling, infection, or drainage and typically requires definitive removal of the cyst and any associated tract to reduce recurrence. Nationally, coding and coverage for congenital head and neck surgical procedures influence surgical case mix, resource allocation, and payer reimbursement for otolaryngology and head & neck surgery services. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find concise clinical context for the procedure, the typical service setting, and what to expect in payer coverage patterns and billing practice considerations. The publication reviews benchmarks for utilization and site-of-service distribution where available, highlights relevant payer policy themes affecting surgical management of congenital neck lesions, and summarizes documentation elements that support medical necessity for excision. Data not available in the input will be noted explicitly where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare42815CPTHead and Neck SurgeryBrachial Cleft CystSurgical ExcisionAmbulatory SurgeryOtolaryngologyPediatric Surgery

Billing Code Overview

CPT code 42815 describes surgical management of a brachial cleft cyst (vestige), a congenital cystic swelling arising from the lateral aspect of the neck due to failure of the second branchial cleft to close during embryologic development. The procedure involves excision of the cystic lesion and any associated tract or sinus to prevent recurrence and address symptoms such as swelling, infection, or drainage.

Service type: Surgical excision of congenital neck cystic lesion
Typical site of service: Hospital outpatient department or ambulatory surgical center, with possible performance in an inpatient setting if clinical complexity or comorbid conditions require admission

Clinical & Coding Specifications

Clinical Context

A typical patient is a pediatric or young adult presenting with a progressively enlarging, painless, fluctuant lateral neck mass along the anterior border of the sternocleidomastoid muscle, often present since birth or noted after an upper respiratory infection. The clinical workflow includes history and physical exam focused on duration, growth, signs of infection or fistula, prior incision and drainage, and airway or swallowing symptoms. Imaging with ultrasound is commonly obtained to confirm a cystic lesion; CT or MRI may be used if deeper tissue extension or surgical planning is needed. Preoperative evaluation includes assessment for active infection (treat with antibiotics or incision and drainage if necessary), informed consent, surgical site marking, and anesthesia evaluation. The procedure is an excision of a branchial cleft cyst (second branchial cleft most common) typically performed in an operating room or outpatient surgical center under general anesthesia for children or local with sedation for selected adults. Intraoperative steps include elliptical skin incision, careful dissection to identify and preserve surrounding neurovascular structures, complete removal of the cyst and tract when present, and layered closure with or without drains. Postoperative care includes monitoring in PACU, analgesia, wound care instructions, and follow-up for pathology results and wound check. Billing is reported with 42815 for excision of a brachial cleft cyst/vestige; documentation should support site, laterality, anesthesia, complexity, and any concurrent procedures or complications.

Coding Specifications

Modifier	Description	When to Use

CPT 42845: Tonsil and Oropharyngeal Resection with Chest Flap Reconstruction

CPT-42894-PHARYNGEAL-WALL-PYRIFORM-SINUS-RECONSTRUCTION-FLAP

CPT 42894: Pharyngeal Wall or Pyriform Sinus Resection with Flap Closure

42820-THE-PROVIDER-REMOVES-THE-TONSILS-AND-ADENOIDS-IN-A-PATIENT

CPT 42820: Tonsillectomy and Adenoidectomy for Patients Under 12

CPT-42810-BRACHIAL-CLEFT-CYST-EXCISION

CPT 42810: Excision of Brachial Cleft Cyst

CPT-42825-PEDIATRIC-TONSILLECTOMY-UNDER-12

CPT 42825: Tonsillectomy in Patients Under 12 Years Old

CPT-42808-PHARYNGEAL-LESION-DESTRUCTION-LASER-CRYOSURGERY

CPT 42808: Removal or Destruction of Pharyngeal Lesion

CPT-42870-LINGUAL-TONSILLECTOMY-BASE-OF-TONGUE

CPT 42870: Lingual Tonsillectomy at Base of Tongue

CPT-42844-TONSIL-AND-OROPHARYNGEAL-RESECTION-WITH-LOCAL-FLAP-CLOSURE

CPT 42844: Tonsil and Oropharyngeal Resection with Local Flap Closure

CPT-42806-NASOPHARYNGEAL-BIOPSY-UNKNOWN-PRIMARY-LESION

CPT 42806: Biopsy of Unknown Primary Lesion of the Nasopharynx

CPT-42842-TONSIL-AND-ADJACENT-STRUCTURE-ABLATIVE-RESECTION

CPT 42842: Tonsil and Adjacent Structure Ablative Resection

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Taxonomy Code	Specialty	Notes
207P00000X	Otolaryngology	Otolaryngologists (ENT surgeons) commonly perform excision of branchial cleft cysts.
208800000X	Pediatric Surgery	Pediatric surgeons frequently manage congenital neck masses in infants and children.
208600000X	General Surgery	General surgeons with head and neck experience perform excision in adult patients.
363A00000X	Plastic and Reconstructive Surgery	Plastic surgeons may be involved for complex resections requiring aesthetic reconstruction.
207L00000X	Head and Neck Surgery	Head and neck specialists perform detailed dissection for deep tracts and recurrent lesions.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Q18.0`	Branchial cleft cyst	Primary diagnosis for which `42815` is performed; congenital origin and direct indication for excision.
`J01.90`	Acute sinusitis, unspecified	May be listed as a comorbid infection precipitating symptomatic cyst enlargement or superinfection requiring drainage prior to excision.
`L02.91`	Cutaneous abscess of other part of head	Relevant when the branchial cleft cyst is acutely infected and presenting as an abscess requiring I&D or antibiotic therapy before definitive excision.
`R22.1`	Localized swelling, mass and lump, neck	Symptom code used when mass identified but specific congenital code not yet documented.
`Z48.02`	Encounter for removal of sutures	Postoperative follow-up code used for routine wound care and suture removal after excision.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`42820`	Excision of branchial cleft cyst or vestige; with partial excision of tract	Performed when the cyst has a superficial tract requiring limited additional dissection; may be billed instead of `42815` if description matches.
`12032`	Repair, intermediate, wounds of face, ears, eyelids, nose, lips; 2.5 cm to 7.5 cm	May be used for layered closure of the skin defect when measuring within size limits if closure repair coding is billed separately and not included in global surgical code.
`20550`	Injection(s); single tendon sheath, or ligament, or ganglion cyst	Used when preoperative aspiration or sclerotherapy of a cyst is performed in clinic prior to definitive excision (rare for branchial cleft cysts).
`43200`	Biopsy, open, intrathoracic lymph node (note: atypical)	Data not available in the input.
`10060`	Incision and drainage of abscess; simple or single	Performed when the branchial cleft cyst is acutely infected and I&D is required prior to definitive excision; may be separate episode of care.

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