CCSD code F4810 – Open salivary gland biopsy

Key takeaways

CCSD code F4810 is open biopsy of lesion of salivary gland, a Minor procedure in section 6.6 Salivary glands of Chapter 6.

F4810 pays for an open surgical sample of a parotid, submandibular or sublingual lesion, not for removing the gland or the whole tumor.

Needle sampling of the parotid is F4640, and gland excisions sit in the F4400 to F4500 range, so the operative note decides the code.

Freedom Health’s Elite schedule (May 2026) lists F4810 at £200 for the specialist and £213 for the anesthetist.

Most rejections trace back to a missing pre-authorization reference, a biopsy coded as an excision, or a note that never names the gland.

Pabau’s claims management software tracks pre-authorization, CCSD codes and Healthcode submissions on the patient record.

CCSD code F4810 is an open biopsy of a salivary gland lesion

CCSD code F4810 is the UK private healthcare procedure code for open biopsy of lesion of salivary gland. The surgeon makes an incision, exposes a lump in the parotid, submandibular or sublingual gland and removes a tissue sample for histology. The gland itself and the bulk of the lesion stay in place.

The code is maintained by the Clinical Coding and Schedule Development Group (CCSD), whose schedule UK private medical insurers use to price procedures. F4810 sits in Chapter 6 (face, mouth, salivary and thyroid), under section 6.6 Salivary glands. Freedom Health’s Elite schedule grades it as a Minor procedure.

F4810 corresponds to OPCS-4 F48.1, which falls under F48 “Other operations on salivary gland”. That mapping helps when an NHS-trained secretary or a hospital coder has recorded the procedure in OPCS-4 first.

Where F4810 sits among the salivary gland codes

Section 6.6 groups every salivary gland procedure in the CCSD schedule, which our overview of CCSD coding for practices explains chapter by chapter. The codes divide by what the surgeon does to the gland. It can be drained, sampled with a needle, sampled through an incision, or partly or fully removed. F4810 is the open sampling step.

The table below lists the section 6.6 codes most often confused with F4810. Descriptors, complexity bands and fees come from the Freedom Health Elite schedule of fees for Chapter 6, dated May 1, 2026.

Fees are Freedom Health Elite rates, not a CCSD list price. Every insurer sets its own fee for F4810, so check the payer’s current schedule before you invoice.

On Freedom Elite, the anesthetist fee for F4810 (£213) is higher than the specialist fee (£200). A practice that budgets the episode from the surgeon’s fee alone will underestimate what the insurer pays out for a general anesthetic case.

What an F4810 biopsy has to document

The operative note is what proves the procedure was an open biopsy and not a needle sample or an excision. An insurer reviewing a queried F4810 claim reads the note against the descriptor, word by word.

Before an F4810 claim goes out, the patient file should hold these records:

• Operative note: A consultant-signed report naming the gland (parotid, submandibular or sublingual), the side and the approach. It should state that an incision was made and a sample of the lesion was taken.
• Extent of removal: A clear statement that the gland, and the bulk of the lesion, were left in place. Without it, a reviewer may ask whether an excision code should have been used.
• Specimen record: The histopathology request and specimen label, confirming tissue was sent for analysis. The pathology report itself is billed by the laboratory, not under F4810.
• Clinical indication: The reason for the biopsy, such as a persistent salivary gland swelling or an earlier needle sample that did not give a diagnosis. Imaging reports that informed the decision belong in the file too.
• Anesthesia record: Whether the biopsy was done under local or general anesthetic. An anesthetist fee is only claimable when an anesthetist attended.
• Consent record: A signed digital consent form or paper equivalent, dated before the procedure. For parotid work, it should record that facial nerve risk was discussed.
• Pre-authorization reference: The authorization number the insurer issued before the procedure, plus the date it was issued.

Patient data in these records is subject to UK GDPR. Clinical documents sent to insurers through Healthcode should be covered by your data processing agreements.

When a different salivary gland code applies

F4810 fits only when the surgeon cuts down to the lesion and takes a sample of it. If the operative note describes a different action, a different section 6.6 code applies. The chart below lines up each action with its code and its Freedom Elite fee.

• Needle sample of the parotid: Fine needle aspiration of the parotid gland is F4640. No incision is made, so F4810 does not apply.
• Drainage of a collection: Incisional drainage of a salivary gland abscess or hematoma is F4600. The incision releases pus or blood rather than sampling a lesion.
• Endoscopy of the duct: Therapeutic sialendoscopy, including washout, is F4830. Open or manual stone removal has its own codes, including F5110, F5120, F5610 and F5611.
• Removal of the gland: Excision of the submandibular gland is F4440, and of the sublingual gland F4450. Parotid excisions run from F4400 to F4430, depending on extent and facial nerve preservation. A combined open and endoscopic removal of the submandibular gland is F5121.
• Removal of a parotid tumor: Extracapsular dissection of a parotid tumor is F4500. If the whole lump came out, the claim is an excision, even when the surgeon called it diagnostic.

Where the operative note describes removing the parotid gland rather than sampling it, F4400 is the code to check first. Its descriptor covers parotid excision other than the total and partial parotidectomy codes, F4410 and F4430. The CCSD schedule repeats that residual pattern elsewhere, where G3800 covers open stomach operations with no dedicated code of their own.

A biopsy taken in the same session as an excision may be treated as part of the excision. Check the CCSD Technical Guide and the insurer before you add F4810 as a second line. When in doubt, compare the operative note with the CCSD schedule descriptor before you submit.

Pre-authorization and insurer requirements for F4810

UK private medical insurers accept CCSD-coded claims for F4810, provided the claim meets their prior authorization and documentation rules. Fee rates differ by insurer and by the consultant’s recognition status. Always check the insurer’s current published fee schedule rather than relying on a figure from another payer.

For Bupa-specific workflows, the Bupa CCSD billing guide covers submission requirements and recognized consultant criteria. Bupa’s fee bands are set out in the Bupa procedure fee schedule.

How to request pre-authorization for F4810

Request authorization before the biopsy goes on the operating list. Most UK insurers will not authorize a surgical procedure retrospectively.

• Give the insurer the patient’s policy number, the consultant’s recognition number and the planned code, F4810.
• Send the referral letter and a short clinical summary if the insurer asks for them. Include any imaging or earlier needle sample result.
• Record the authorization number, the date it was issued and the name of the insurer representative. All three are needed for the Healthcode claim.
• If the plan might change to an excision on the day, ask the insurer whether the authorization can cover both codes.

Common reasons F4810 claims are rejected

F4810 claims fail for a short list of avoidable reasons. Most of them come down to the code and the operative note telling different stories.

• Missing or invalid pre-authorization reference: The claim arrives without an authorization number, or the number does not match the insurer’s records. This is the most common cause of non-payment.
• Biopsy coded as an excision, or the reverse: The note says the whole lesion or gland was removed, but the claim says F4810. Or the note describes a biopsy and the claim carries an F44xx or F4500 code.
• Needle sample billed as an open biopsy: A fine needle aspiration of the parotid was claimed as F4810 instead of F4640. The insurer compares the note with the descriptor and spots the missing incision.
• Gland or side not recorded: The operative note does not say which gland was sampled or on which side. The reviewer cannot match the claim to the procedure, so it is queried.
• Consultant recognition status: The consultant is not recognized by the insurer for the specialty, or their recognition has lapsed.
• Fee above the schedule rate: An invoice above the insurer’s published fee for F4810 is settled at the schedule rate at best. It may also trigger a shortfall query.
• Anesthetist fee without an anesthetist: An anesthetist claim was raised for a biopsy done under local anesthetic by the surgeon alone.

Other fees billed alongside F4810

F4810 pays the consultant for the biopsy. Other parts of the episode are claimed separately, usually by someone else.

Unbundling rules vary between payers. Healix publishes detailed guidance on which codes can share a claim, so check it before adding any second line to an F4810 claim.

How to submit an F4810 claim through Healthcode

Healthcode is the standard electronic route for CCSD-coded claims to UK insurers. The steps below are a guide only, because Healthcode updates its interface from time to time.

1. Log in to Healthcode: Use your practice’s credentials and open the claims area for the patient’s insurer.
2. Enter patient and policy details: Add the patient’s full name, date of birth, policy number and the pre-authorization reference for this procedure.
3. Enter the procedure code: Type F4810 in the procedure code field. Healthcode checks it against the insurer’s current schedule.
4. Add the date and site: Record the date of the biopsy and, where the form allows, the gland and side.
5. Enter the fee: Charge at or below the insurer’s schedule rate for F4810. A higher fee is queried or paid at the schedule amount.
6. Attach supporting documents: Some insurers ask for the operative note or a clinical summary at submission. Check the payer’s requirements in Healthcode first.
7. Submit and record the reference: Healthcode returns a submission reference once the claim is sent. Store it next to the pre-authorization number on the patient record.
8. Monitor the claim: If the insurer returns a query, answer it within the response window so the claim is not rejected.

How Pabau keeps F4810 claims accurate

A salivary gland biopsy claim passes through at least four sets of hands before an insurer sees it:

• The secretary books the operating list.
• The consultant writes the operative note.
• The laboratory sends back the histology.
• The billing team raises the invoice.

Each handover is a chance for the pre-authorization number or the code to be retyped wrongly.

Pabau’s claims management software keeps the authorization reference, the CCSD code and the Healthcode submission on the patient’s record. Your team can check the claim against the signed operative note before it leaves the practice. If an insurer raises a query later, the audit trail shows what was submitted and when.

Digital consent forms and clinical notes sit on the same record, so the documents an insurer asks for are already in one file. That makes it quicker to answer an F4810 audit request.

Keep F4810 claims tied to the operative note

Pabau tracks pre-authorization, CCSD codes and Healthcode submissions on one patient record, so your billing team spends less time chasing rejected claims.

Book a demo

Conclusion

F4810 is a narrow code. It pays for an open sample of a salivary gland lesion. The gland and the bulk of the lesion have to stay where they are.

The coding decision is settled when the surgeon writes the operative note. If the note says “open biopsy”, names the gland and confirms what was left in place, the claim matches the descriptor. If the lump came out whole, the claim belongs to an excision code, whatever the referral said.

Settle the plan with the insurer at pre-authorization, including what happens if the biopsy becomes an excision on the day. To see how Pabau keeps the authorization, the note and the Healthcode claim on one record, book a demo.

Continue your research

Need a full breakdown of Bupa’s CCSD requirements? Bupa CCSD codes covers recognized consultant criteria, submission rules, and common rejection causes for Bupa-insured patients.

Billing a Bupa patient for a salivary gland procedure? Bupa procedure codes fee schedule maps procedure categories to Bupa’s fee bands.

Did the surgeon remove the whole submandibular gland? CCSD code F4440 covers excision of the submandibular gland and how to bill it.

Was the sublingual gland excised instead? CCSD code F4450 covers excision of the sublingual gland and the claim it needs.

Frequently asked questions