Outpatient Facility Coding Alert

Use all the resources at your disposal to reach the correct coding choice.

The process of coding a tricky or convoluted surgical procedure can trip up even the most experienced surgical coders. As an outpatient facility coder, you know that there are a lot of moving parts in the surgical coding process — and we’re here to break down each one of them with a clinical example.

While you’ll always want to first take the most traditional route of code selection using the CPT® index, you’ll quickly find that with some surgical procedures that is simply not enough. Instead, you’ve got to explore some less common coding avenues in pursuit of the correct choice.

Use the advice and techniques in this clinical scenario to help better equip you to handle any operative report that comes your way.

Find Success Using a Step-By-Step Approach

Procedure: 30-year-old patient undergoes right composite resection of oropharynx including right tonsil, and right base of tongue.

The operative description alone makes for a challenging clinical scenario to code. First, you will want to address the composite resection of the oropharynx. A proper understanding of surgical terminology is important in order to correctly code this portion of the procedure. Specifically, you’re going to have to consider terms synonymous with “resection” in order to reach the correct surgical code within the CPT^® manual. For the purposes of CPT^® coding, you can consider terms such as “removal” and “excision” to be synonymous with “resection.”

However, you won’t find the code you’re looking for by searching for terms “Removal” or “Resection” in the index. Using the term “Excision” can get you to the correct final result, but you’ll find an easier path by using the index term “Pharynx.” Pharynx ⇒ Excision will give you the options of “Partial” or “Resection.” Let’s break down each of these options to determine the correct choice:

Let Your Anatomical Knowledge Lead the Way

Choosing “Partial” in the CPT^® index will lead you to code 42890 (Limited pharyngectomy). Since the oropharynx is a component of the pharynx, this option sounds entirely logical on the surface. The keyword “Resection,” on the other hand, leads you to consider one of two codes:

• 42892 — Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls
• 42894 — Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or free muscle, skin, or fascial flap with microvascular anastomosis.

As you can see, without a description of the provider’s closure technique, it’s impossible to determine the correct code. Making a decision between these coding options requires a strong anatomical understanding of the pharynx. Fortunately, you can immediately rule out 42894 as an option since it refers to the entirety of the pharyngeal wall. On the other hand, 42892 involves a resection of the lateral pharyngeal wall. If the lateral pharyngeal wall overlaps with the oropharynx, then you might consider 42892 as an accurate representation of the provider’s services. Have a look at the clinical responsibility for 42892:

• “The physician treats pathological condition in oral cavity, and pharynx through surgical removal of either piriform (pear–shaped) recess or lateral wall of pharynx (which is composed of tonsil, tonsillar fossa, and tonsillar faucial pillars). The repair of the surgical wound is achieved directly by reapproxi­mation of lateral and posterior pharyngeal walls through advancement flaps technique.”

You could argue that this description adds more confusion than clarity to your decision-making process. As long as your knowledge of ear, nose, and throat (ENT) anatomy is sound, you know that the lateral wall of the pharynx is one component of the oropharynx. This leads you to the conclusion that you should include the right tonsillectomy as a component of the oropharynx resection when reporting code 42892.

Decide Between 42890 and 42892

At this point, you’ve made it as far as deciding between codes 42890 and 42892. However, upon further examination, you should feel confident ruling out 42892 as an option unless the operative report contradicts the procedure header. That’s because a resection of the lateral wall of the pharynx does not fully encompass the extent of the surgeon’s work. Since the oropharynx includes more than just the lateral pharyngeal wall, code 42892 would only include a portion of the services rendered.

With further analysis, it’s safe to determine that the code description for 42890 accurately describes the surgeon’s work in the removal of the oropharynx, since by definition, it’s a limited portion of the entirety of the pharynx. Consider this portion of the Stedman’s Medical Dictionary definition of the pharynx:

• “The superior expanded portion of the alimentary tract, between the mouth and nasal cavities (superiorly and anteriorly) and the esophagus (inferiorly); consisting of nasopharynx, oropharynx, and laryngopharynx.”

Additionally, the clinical responsibility for code 42890 goes on to explain that, after the surgeon gains access to the pharynx, “pharyngectomy incisions are then performed to remove a portion of pharynx (i.e., pharyngeal lesion).”

Without the operative report, it’s impossible to determine whether to separately report the services for the tonsillectomy and base of tongue resection. If the surgeon resects the entirety of the oropharynx, it’s conceivable that 42890 encompasses all three services. Furthermore, consider this definition of the oropharynx provided by the National Cancer Institute (NCI):

• “The part of the throat at the back of the mouth behind the oral cavity. It includes the back third of the tongue, the soft palate, the side and back walls of the throat, and the tonsils.”

You’ll have to confer with your provider to make the best determination as to whether to include code 42826 (Tonsillectomy, primary or secondary; age 12 or over) with modifier 52 (Reduced Services) and the appropriate base of tongue resection code.

As for the base of the tongue resection, you’ll be choosing between codes 41530 (Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session) and 41120 (Glossectomy; less than one-half tongue).

“The procedure header does not tell us how the base of tongue was resected,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “If it was reduced via radiofrequency, 41530 would apply. If it was resected with a scalpel, you would report a partial glossectomy, 41120,” Cobuzzi explains.

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