How To Use CPT Code 42106

CPT 42106 describes the excision of a lesion from the palate or uvula, followed by simple primary closure. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 42106?

CPT 42106 can be used to describe the excision of a lesion from the palate or uvula, with subsequent closure of the incision using a simple primary closure technique. This code is used when a healthcare provider removes a damaged or diseased tissue area from the palate or uvula, and then closes the site of incision using sutures or other simple repair methods.

2. Official Description

The official description of CPT code 42106 is: ‘Excision, lesion of palate, uvula; with simple primary closure.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate anesthesia and prepping the target site in the palate or uvula.
2. An elliptical-shaped incision is made at the lesion site, including a small margin of surrounding tissue.
3. The lesion, along with the surrounding tissue, is removed and sent to pathology for further analysis.
4. The provider flushes the site with sterile saline and applies antibiotics to prevent infection.
5. The incision site is closed using a simple primary closure technique, such as sutures.

4. Qualifying circumstances

CPT 42106 is used for patients who require the excision of a lesion from the palate or uvula. The procedure is typically performed when there is damaged or diseased tissue in these areas that needs to be removed. The healthcare provider must use a simple primary closure technique to close the incision site.

5. When to use CPT code 42106

CPT code 42106 should be used when a healthcare provider performs the excision of a lesion from the palate or uvula and closes the incision using a simple primary closure technique. This code is appropriate for cases where the lesion removal and closure are the primary focus of the procedure.

6. Documentation requirements

To support a claim for CPT 42106, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for lesion excision
• Description of the lesion and its location in the palate or uvula
• Date of the procedure
• Details of the excision procedure, including the size of the incision and the extent of tissue removal
• Method of closure used, such as sutures
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 42106, ensure that the excision of the lesion from the palate or uvula is performed, and the incision is closed using a simple primary closure technique. There are no specific guidelines regarding reporting CPT 42106 with other codes. However, it is important to review other codes related to palate and uvula excision (such as CPT codes 42104 and 42140) to ensure accurate coding for the specific case.

8. Historical information

CPT 42106 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs the excision of a lesion from the palate of a patient and closes the incision using sutures.
2. During a procedure, a lesion is removed from the uvula of a patient, and the incision site is closed with a simple primary closure technique.
3. A healthcare provider excises a lesion from the palate of a patient and performs a simple primary closure to close the incision.
4. Using a simple primary closure technique, a lesion is excised from the uvula of a patient by a healthcare provider.
5. A lesion is removed from the palate of a patient, and the incision site is closed using sutures by a healthcare provider.
6. A healthcare provider performs the excision of a lesion from the uvula of a patient and closes the incision using a simple primary closure technique.
7. During a procedure, a lesion is removed from the palate of a patient, and the incision site is closed with a simple primary closure technique.
8. A healthcare provider excises a lesion from the uvula of a patient and performs a simple primary closure to close the incision.
9. Using a simple primary closure technique, a lesion is excised from the palate of a patient by a healthcare provider.
10. A lesion is removed from the uvula of a patient, and the incision site is closed using sutures by a healthcare provider.