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The procedure described by CPT® Code 42104 involves the excision of a lesion located on the palate or uvula, which are critical components of the oral cavity. The palate serves as the roof of the mouth and is divided into two parts: the hard palate, which is bony and forms the anterior section, and the soft palate, which is muscular and forms the posterior section. The uvula, a small conical structure, extends from the soft palate and is made up of connective tissue, racemose glands, and muscular fibers. During this procedure, a thorough examination of the roof of the mouth is conducted to identify the lesion present on the palate or uvula. Once the lesion is located, a margin of healthy tissue surrounding it is determined to ensure complete excision. An incision is then made through the mucosa and submucosa, encircling the lesion to facilitate its removal. After excising the lesion, it is sent to a laboratory for histologic evaluation, which is reported separately. It is important to note that this procedure is coded as 42104 when the surgical wound is intentionally left open to heal by secondary intention, as opposed to other codes that apply when the wound is closed using different techniques.
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The excision of a lesion on the palate or uvula, as described by CPT® Code 42104, is indicated for various conditions that may affect these structures. The following are explicitly provided indications for this procedure:
The procedure for excising a lesion of the palate or uvula involves several critical steps, which are detailed as follows:
Post-procedure care following the excision of a lesion on the palate or uvula involves monitoring for any complications and ensuring proper healing. Patients are typically advised to maintain good oral hygiene and may be instructed to avoid certain foods that could irritate the surgical site. Since the wound is left open to heal by secondary intention, it is important to monitor for signs of infection or delayed healing. Follow-up appointments may be scheduled to assess the healing process and discuss the results of the histologic evaluation. Additionally, patients should be informed about potential symptoms to watch for, such as increased pain or swelling, which may indicate complications.
| Short Descr | EXCISION LESION MOUTH ROOF | Medium Descr | EXC LESION PALATE UVULA W/O CLOSURE | Long Descr | Excision, lesion of palate, uvula; without closure | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 2 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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