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The CPT® Code 42842 refers to a surgical procedure known as radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone, performed without closure. This procedure is primarily indicated for the treatment of primary malignant neoplasms located in the oropharynx, specifically in the tonsils, tonsillar pillars, and retromolar trigone areas. The tonsils, particularly the palatine tonsils, are clusters of lymphoid tissue located laterally at the back of the throat, nestled between the anterior and posterior tonsillar pillars, which are formed by the palatoglossus and palatopharyngeus muscles, respectively. The retromolar trigone is a small mucosal region situated behind the wisdom teeth. During the procedure, the extent of the tumor is assessed through various diagnostic studies, including radiographic imaging and biopsies, to determine the precise area that requires resection. The surgical approach may involve either an oral route or a neck incision, depending on the tumor's location and extent. The surgeon excises the tumor along with a margin of healthy tissue to ensure complete removal of malignant cells. To confirm the absence of cancerous tissue, frozen sections of the excised tissue are sent for laboratory analysis. If malignant tissue is detected, further excision is performed until clear margins are achieved. Notably, in the case of CPT® Code 42842, the surgical site is intentionally left open to heal by secondary intention, contrasting with other codes that involve closure techniques using local or distant flaps.
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The radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone is indicated for the following conditions:
The procedure involves several critical steps to ensure the complete removal of malignant tissue. First, the surgeon evaluates the extent of the tumor through diagnostic imaging and biopsies to determine the precise area that requires resection. This assessment is crucial for planning the surgical approach, which may be performed either through the mouth or via a neck incision, depending on the tumor's location. Once the surgical site is prepared, the surgeon identifies the area to be resected, which may include the tonsil, tonsillar pillars, and/or retromolar trigone.
Next, the surgeon excises the tumor along with a margin of healthy tissue to ensure that all malignant cells are removed. During the procedure, frozen sections of the excised tissue are sent to the laboratory for immediate analysis. This step is vital as it allows the surgeon to confirm whether all cancerous tissue has been successfully removed. If the frozen section analysis indicates the presence of malignant cells, the surgeon will continue to excise additional tissue until clear margins are achieved.
After the resection is completed, the area is left exposed to heal by secondary intention, which is a key aspect of CPT® Code 42842. This means that the surgical site will not be closed with sutures or flaps, allowing the body to heal naturally over time. This approach may differ from other related procedures that involve closure techniques, such as local flap closure or distant flap closure, which are described under different CPT® codes.
Post-procedure care for patients undergoing radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone typically involves monitoring for any signs of complications, such as infection or excessive bleeding. Patients may experience pain and discomfort in the surgical area, which can be managed with appropriate pain relief medications. It is essential for patients to follow their healthcare provider's instructions regarding diet, activity level, and follow-up appointments to ensure proper healing and recovery. Additionally, patients may require further evaluation and treatment based on the pathology results from the excised tissue to determine if additional interventions are necessary.
| Short Descr | EXTENSIVE SURGERY OF THROAT | Medium Descr | RADICAL RESECTION TONSIL W/O CLOSURE | Long Descr | Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure | 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) | 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | LT | Left side (used to identify procedures performed on the left side of the body) | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | 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) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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