© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 42845 refers to a surgical procedure known as a radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone, with closure achieved using a different type of flap. 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 are sent for laboratory analysis during the procedure. If any malignant tissue remains, further excision is performed until clear margins are achieved. In contrast to other related procedures, such as CPT® Code 42842, where the resection site is left to heal naturally, or CPT® Code 42844, which involves local flap closure using adjacent tissue, CPT® Code 42845 utilizes a different flap technique. This involves harvesting tissue from another area of the body, which is then shaped and sutured into place over the surgical site in the oropharynx using microvascular techniques. The donor site from which the flap is taken is also sutured to facilitate healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone, as described by CPT® Code 42845, is indicated for the following conditions:
The procedure involves several critical steps to ensure the complete removal of malignant tissue while preserving surrounding healthy structures. The following steps outline the process:
Post-procedure care following a radical resection using CPT® Code 42845 includes monitoring for any complications such as bleeding or infection at both the surgical site and the donor site. Patients may require pain management and should be advised on dietary modifications to accommodate healing in the oropharynx. Follow-up appointments are essential to assess recovery and ensure that no malignant tissue remains. The surgical team will provide specific instructions regarding activity restrictions and signs of complications that should prompt immediate medical attention.
| Short Descr | EXTENSIVE SURGERY OF THROAT | Medium Descr | RADICAL RESCJ TONSIL CLOSURE W/OTHER FLAP | Long Descr | Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap | 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 | Inpatient Procedures, not paid under OPPS | 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 |
| 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. | 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). | 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) | RT | Right side (used to identify procedures performed on the right side of the body) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.