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The procedure described by CPT® Code 42160 involves the destruction of lesions located on the palate or uvula. This process begins with a thorough examination of the lesion to determine the most suitable method of destruction. Local anesthesia may be administered to ensure patient comfort during the procedure. There are several techniques available for lesion destruction, including cryosurgery, which utilizes liquid nitrogen to freeze the lesion, effectively killing the abnormal tissue. Another common approach is surgical curettage, which involves scraping away the lesion, often followed by electrosurgery to further ensure complete removal. Additionally, chemosurgery may be employed, where a chemotherapeutic agent, such as 5-fluorouracil (5-FU), is applied to destroy the lesion chemically. Each of these methods is selected based on the specific characteristics of the lesion and the overall health of the patient, ensuring a tailored approach to treatment.
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The procedure is indicated for the treatment of lesions on the palate or uvula that may require destruction due to various reasons, including but not limited to:
The procedure for the destruction of lesions on the palate or uvula involves several key steps, each critical to ensuring effective treatment.
After the procedure, patients may be monitored for any immediate reactions to the treatment. Post-procedure care may include instructions on managing any discomfort, potential swelling, or bleeding. Patients are typically advised on signs of infection or complications to watch for and when to seek further medical attention. Follow-up appointments may be scheduled to assess the healing process and ensure that the lesion has been adequately treated.
| Short Descr | TREATMENT MOUTH ROOF LESION | Medium Descr | DSTRJ LESION PALATE/UVULA THERMAL CRYO/CHEM | Long Descr | Destruction of lesion, palate or uvula (thermal, cryo or chemical) | 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) | 0 - 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) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 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. | 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 | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | LT | Left side (used to identify procedures performed on the left side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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