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The procedure described by CPT® Code 42860 involves the excision of tonsil tags, which are small remnants of tonsil tissue that may remain after a previous tonsillectomy. These tags can become symptomatic, leading to discomfort or other issues, necessitating their removal. The excision process may involve various techniques, including sharp and blunt dissection using scissors and curettes, as well as advanced methods such as cautery, radiofrequency or laser ablation, and the use of a harmonic scalpel. During the procedure, it is crucial to manage any bleeding that may occur, which can be controlled through methods such as applying pressure, using suture ties, or employing cautery techniques. This procedure is typically performed in a surgical setting and requires careful attention to detail to ensure complete removal of the tonsil tags while minimizing complications.
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The excision of tonsil tags is indicated in cases where these remnants of tonsil tissue become symptomatic. Symptoms may include discomfort, difficulty swallowing, or recurrent infections associated with the remaining tonsil tissue. The procedure is performed to alleviate these symptoms and prevent further complications that may arise from the presence of tonsil tags.
The procedure for excising tonsil tags involves several key steps to ensure effective removal and minimize complications. Initially, the patient is positioned appropriately, and anesthesia is administered to ensure comfort during the procedure. The surgeon then carefully identifies the tonsil tags that need to be excised.
Post-procedure care for patients who have undergone the excision of tonsil tags typically includes monitoring for any signs of bleeding or infection. Patients may be advised to rest and avoid strenuous activities for a short period following the procedure. Pain management may be necessary, and the use of analgesics can be recommended to alleviate discomfort. Follow-up appointments may be scheduled to ensure proper healing and to address any concerns that may arise after the procedure.
| Short Descr | EXCISION OF TONSIL TAGS | Medium Descr | EXCISION TONSIL TAGS | Long Descr | Excision of tonsil tags | 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 | 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 | 30 - Tonsillectomy and/or adenoidectomy |
| 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. | 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 | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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