Resolved Surgery ?

[DonnaA_43539]

Need help with cpt for this surgery, I believe 42107, but center approved 21030 & 14040.
Recurrent trauma to roof of the mouth. Pt has developed a large bony protuberance in this area along with central ulceration. They were felt to benefit from Excision of this.
Anesthesia Service using the GlideScope intubation and and oral RAE tube. At this point a MCivor mouth gag was inserted into the oral cavity and used to hold the orotracheal tube out ot the operative field and hold the mouth open. This allowed exposure of the roof of the mouth. The area was injected with approximately 3 mL or lidocaine and epinephrine the bony protuberance. Using a series of periosteal elevators the mucosa was advanced off this area and the bony mass was exposed. Next, using a 4 mm conical burr consistent with pineapple burr on the pneumatic drill, the bony mass was excised. It was excised flush to the remaining portion of the hard palate. No palate fistula was created. At this point, hemostasis was achieved with Bovie Cautery. The mucosal advancement flaps were elevated and reapproximated back to midline with chromic suture.

Thank You for any Confirmation on this.

 

[Alicia]

It seems like there's a discrepancy in the CPT codes used for the surgery you described. Here's a breakdown to help clarify:

1. Procedure Description: The surgery involved excising a bony protuberance from the roof of the mouth, which developed due to recurrent trauma. The procedure included mucosal advancement flaps to close the area.
2. CPT Code Options:
   
   • 42107: This code is for the excision of a lesion from the palate or uvula with local flap closure. Given that your procedure involved excising a bony mass and closing the area with mucosal advancement flaps, this code seems relevant.
   • 21030: This code is used for excising a benign tumor from the maxilla (upper jaw) or zygoma (cheekbone). While it involves excision, it doesn't specifically address the palate or the use of local flaps for closure.
   • 14040: This code is for tissue transfer procedures involving areas like the face, cheeks, chin, mouth, neck, axilla, or groin. It doesn't directly apply to the excision of a bony protuberance from the palate.
3. Recommendation: Based on the procedure details, 42107 seems more appropriate because it specifically addresses excision with local flap closure on the palate. However, if the center has approved 21030 and 14040, there might be specific reasons related to their policies or insurance coverage that you should discuss further with them.
4. Next Steps: It would be beneficial to review the procedure notes again and discuss with the coding team or the center why 21030 and 14040 were chosen over 42107. Clarifying the rationale behind these choices can help ensure accurate billing and compliance with coding guidelines.