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The procedure described by CPT® Code 42844 involves a radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone, which are critical areas in the oropharynx where primary malignant neoplasms commonly occur. The tonsils, specifically the palatine tonsils, are clusters of lymphoid tissue located laterally at the back of the throat, nestled between the anterior and posterior tonsillar pillars. The anterior tonsillar pillar is formed by the palatoglossus muscle, while the posterior pillar is formed by the palatopharyngeus muscle. The retromolar trigone is a small mucosal region located behind the wisdom teeth. The procedure is typically indicated when there is a malignant tumor present in these areas, and the extent of the tumor is assessed through various diagnostic studies, including radiographic imaging and biopsies. During the surgery, the physician identifies the tumor and performs a complete resection, ensuring that a margin of healthy tissue is included to minimize the risk of residual malignancy. The resection can be approached either orally or through a neck incision, depending on the tumor's location and extent. To confirm the complete removal of malignant tissue, frozen sections are sent for laboratory analysis during the procedure. If any malignant tissue remains, further excision is performed. Unlike CPT® Code 42842, where the resection site is left to heal by secondary intention, CPT® Code 42844 includes the closure of the surgical site using a local flap. This involves mobilizing adjacent tissue, such as from the tongue or buccal area, which is then rotated over the resection site and sutured in place, with the donor site also being sutured for closure.
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The procedure described by CPT® Code 42844 is indicated for the surgical management of malignant neoplasms located in the oropharynx, specifically in the tonsils, tonsillar pillars, and retromolar trigone. The following conditions may warrant this radical resection:
The procedure for CPT® Code 42844 involves several critical steps to ensure the effective removal of malignant tissue while preserving surrounding structures. The following procedural steps are performed:
Post-procedure care following a radical resection using CPT® Code 42844 includes monitoring for complications such as bleeding, infection, and proper healing of the surgical site. Patients may experience pain and discomfort, which can be managed with appropriate analgesics. Follow-up appointments are essential to assess the healing process and to evaluate the results of the frozen section analysis. Additional treatments, such as radiation or chemotherapy, may be considered based on the pathology results and the extent of the malignancy. Patients are advised to maintain hydration and follow dietary recommendations to facilitate recovery.
| Short Descr | EXTENSIVE SURGERY OF THROAT | Medium Descr | RADICAL RESCJ TONSIL CLOSURE W/LOCAL FLAP | Long Descr | Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal) | 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 | 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 |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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). | 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). | 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) | 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) | 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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