How To Use CPT Code 42844

CPT 42844 describes the radical resection of tonsil, tonsillar pillars, and/or retromolar trigone with closure using local flap. 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 42844?

CPT 42844 can be used to describe the surgical procedure of removing the tonsils, tonsillar pillars, and/or the retromolar trigone, along with closure using local tissue flaps. This procedure is often performed to remove cancerous growths in these areas.

2. Official Description

The official description of CPT code 42844 is: ‘Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal).’ This procedure involves the complete removal of the specified structures, along with closure using local tissue flaps, such as those from the tongue or buccal area.

3. Procedure

1. The surgeon begins by making an incision in the neck region, accessing the tonsils, tonsillar pillars, and/or the retromolar trigone.
2. If necessary, portions of the maxilla or mandible that are affected, such as by a malignant neoplasm, may also be removed.
3. The surgeon then proceeds to perform a radical resection, which involves the complete removal of the specified structures, including their associated vascular supply and lymph nodes, along with a sufficient margin of surrounding tissues.
4. After the resection, the resulting wound is closed using local tissue rotational flaps from adjacent structures, such as the tongue or buccal area.
5. This procedure is typically performed to ensure the complete removal of diseased tissue, especially in cases involving cancerous growths.

4. Qualifying circumstances

CPT 42844 is performed in cases where there is a need for a radical resection of the tonsils, tonsillar pillars, and/or the retromolar trigone, along with closure using local tissue flaps. This procedure is often indicated for patients with cancerous growths in these areas. It is important to note that the procedure should be performed by a qualified surgeon with expertise in this specific surgical technique.

5. When to use CPT code 42844

CPT code 42844 should be used when a radical resection of the tonsils, tonsillar pillars, and/or the retromolar trigone is performed, along with closure using local tissue flaps. This code is appropriate for cases involving the removal of cancerous growths in these areas. It should not be used for procedures without closure using local flaps or when closure is performed using flaps other than those from the tongue or buccal area.

6. Documentation requirements

To support a claim for CPT 42844, the surgeon must document the following information:

• Patient’s diagnosis and the need for a radical resection
• Specific details of the procedure performed, including the structures removed and the closure technique used
• Date of the procedure
• Any additional procedures performed, such as the removal of portions of the maxilla or mandible
• Details of the closure technique, including the use of local tissue flaps
• Any complications or unexpected findings during the procedure
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 42844, ensure that the procedure meets the criteria for a radical resection of the specified structures with closure using local tissue flaps. It is important to accurately document the details of the procedure and provide the necessary supporting documentation. Additionally, be aware of any specific payer guidelines or requirements for reporting this code.

8. Historical information

CPT 42844 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A surgeon performs a radical resection of the tonsils, tonsillar pillars, and retromolar trigone, along with closure using a local tongue flap, for a patient with cancerous growths in these areas.
2. During a surgical procedure, a surgeon removes the tonsils, tonsillar pillars, and retromolar trigone, along with portions of the maxilla affected by a malignant neoplasm, and closes the wound using a local buccal flap.
3. A patient undergoes a radical resection of the tonsils, tonsillar pillars, and retromolar trigone, along with closure using local tissue flaps from adjacent structures, to remove cancerous growths.
4. A surgeon performs a radical resection of the tonsils, tonsillar pillars, and retromolar trigone, along with closure using a local tongue flap, for a patient with advanced stage cancer in these areas.
5. During a surgical procedure, a surgeon removes the tonsils, tonsillar pillars, and retromolar trigone, along with portions of the mandible affected by a malignant neoplasm, and closes the wound using a local buccal flap.
6. A patient undergoes a radical resection of the tonsils, tonsillar pillars, and retromolar trigone, along with closure using local tissue flaps from adjacent structures, to remove cancerous growths.
7. A surgeon performs a radical resection of the tonsils, tonsillar pillars, and retromolar trigone, along with closure using a local tongue flap, for a patient with cancerous growths in these areas.