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Official Description

Resection of palate or extensive resection of lesion

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 42120 involves the resection of the palate or an extensive resection of a lesion located on the hard or soft palate. This surgical intervention is primarily indicated for the removal of benign tumors, as well as premalignant or malignant lesions that may affect the palate's integrity and function. The process begins with the creation of a mucosal incision that outlines the periphery of the lesion or the specific area of the palate that requires resection. In cases where the lesion is situated in the soft palate, the incision extends through the submucosal and connective tissue layers, allowing for the removal of the affected region along with a margin of healthy tissue to ensure complete excision. Conversely, if the lesion involves the hard palate, the incision penetrates through the periosteum, which is then elevated to access the underlying bone. An osteotome or oscillating saw is employed to cut through the affected bone, facilitating the removal of the lesion along with an adequate margin of healthy tissue. The excised tissue is subsequently sent for pathology examination to assess the nature of the lesion. After the resection, the surgical defect may be closed using lateral relaxing incisions and a local mucosal advancement flap, with primary closure of the donor site. In instances where larger defects are present, a local palatal flap may be utilized, allowing the donor site to heal by secondary intention. Additionally, for reconstruction purposes, separately reportable extraoral tissue grafts may be employed. It is important to note that the excision of bone typically necessitates separate reporting for reconstruction using a palatal obturator, highlighting the complexity and comprehensive nature of this surgical procedure.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 42120 is indicated for the following conditions:

  • Benign Tumors - These are non-cancerous growths that may require removal to prevent complications or discomfort.
  • Premalignant Lesions - These lesions have the potential to develop into cancer and are excised to mitigate the risk of progression.
  • Malignant Lesions - Cancerous growths on the hard or soft palate necessitate resection to remove the tumor and surrounding affected tissue.

2. Procedure

The procedure involves several critical steps to ensure the effective resection of the lesion:

  • Step 1: Incision Creation - A mucosal incision is made around the periphery of the lesion or the area of the palate designated for resection. This initial incision is crucial for accessing the underlying tissues and ensuring a clear margin around the lesion.
  • Step 2: Soft Palate Resection - If the lesion is located in the soft palate, the incision is extended through the submucosal and connective tissue layers. The surgeon carefully removes the involved region along with a margin of healthy tissue to ensure complete excision and minimize the risk of recurrence.
  • Step 3: Hard Palate Resection - In cases where the hard palate is affected, the incision is deepened through the periosteum, which is then elevated. An osteotome or oscillating saw is utilized to cut through the involved bone, allowing for the removal of the lesion along with a margin of healthy tissue.
  • Step 4: Pathology Examination - The excised tissue is sent for separate pathology examination to determine the nature of the lesion, which is essential for further treatment planning.
  • Step 5: Closure of Surgical Defect - The surgical defect may be closed using lateral relaxing incisions and a local mucosal advancement flap. In cases of larger defects, a local palatal flap may be employed, with the donor site allowed to heal by secondary intention.
  • Step 6: Reconstruction - For reconstruction purposes, separately reportable extraoral tissue grafts may be utilized. Additionally, if bone excision is performed, separate reporting for reconstruction with a palatal obturator is typically required.

3. Post-Procedure

Post-procedure care involves monitoring the surgical site for signs of infection and ensuring proper healing. Patients may be advised on dietary modifications to avoid irritation to the surgical area. Follow-up appointments are essential to assess healing and to review pathology results. Any necessary additional treatments or interventions will be discussed based on the findings from the pathology examination. Pain management and instructions for oral hygiene may also be provided to facilitate recovery.

Short Descr REMOVE PALATE/LESION
Medium Descr RESCJ PALATE/EXTENSIVE RESCJ LESION
Long Descr Resection of palate or extensive resection of lesion
Status Code Active Code
Global Days 090 - Major Surgery
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) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
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 Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P5E - Ambulatory procedures - other
MUE 1
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).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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)
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
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