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42840

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🩺 CPT 42840: Radical Resection of Tonsil Area (Without Closure)

Code Description

Official AMA Description: Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure

This CPT code describes a significant surgical procedure performed to remove a malignant tumor (cancer) located in the oropharynx, specifically involving the tonsil and surrounding tissues. This is far more extensive than a standard tonsillectomy (42825, 42826) which is typically done for infection or obstruction.

A “radical resection” implies the removal of the primary tumor with a wide margin of normal tissue to ensure all cancerous cells are excised. The key anatomical structures involved are:

  • Tonsil: The palatine tonsil itself.
  • Tonsillar Pillars: The folds of tissue in front of (anterior pillar) and behind (posterior pillar) the tonsil.
  • Retromolar Trigone: The triangular area of gum tissue behind the last molar tooth.

The defining characteristic of 42840 is that the surgical wound is left open to heal by secondary intention (granulation) or is planned for a subsequent reconstructive procedure. This is in direct contrast to its companion code, 42841, which includes primary closure.

Layman’s Terms

In simpler terms, this procedure is for removing a cancerous tumor from the back of the throat in the tonsil area. The surgeon removes the tumor along with a safety border of healthy tissue around it. For this specific code, the hole created by the surgery is not stitched or closed up at the end of the procedure.

Coding & Billing Information

wRVU (Work Relative Value Units)

  • wRVU: 16.50
    • Note: wRVU values are subject to annual changes by CMS. This value is an approximation and should be verified against the current year’s Physician Fee Schedule.

Assistant at Surgery

  • Assistant Payable: Yes.
    • This procedure has a CMS Physician Fee Schedule indicator of ‘2’, meaning an assistant surgeon is almost always medically necessary and payable. The complexity and potential for significant bleeding in this anatomical region justify the need for a second surgeon.

CPT codes are used for professional billing and do not directly map to an MS-DRG, which is used for inpatient facility billing. The MS-DRG is determined by the patient’s principal diagnosis (ICD-10), secondary diagnoses (comorbidities/complications), and the principal procedure performed (ICD-10-PCS code).

A patient undergoing this procedure would likely fall into one of the following MS-DRG categories:

  • MS-DRG 146-148: Major Head and Neck Procedures
  • MS-DRG 129: Major Head & Neck Procedures with CC/MCC or Major Laryngectomy

ICD-10 Diagnosis Considerations & HCC

CPT codes themselves do not have HCC values. Hierarchical Condition Category (HCC) scoring is linked to ICD-10-CM diagnosis codes to predict healthcare costs for patients in risk-adjustment models (like Medicare Advantage). Below are common ICD-10-CM codes that would medically justify procedure 42840, along with their associated HCC categories.

ICD-10 CodeDescriptionHCC Category
C09.0Malignant neoplasm of tonsillar fossaHCC 9: Malignant Neoplasm of Head and Neck
C09.1Malignant neoplasm of tonsillar pillar (anterior) (posterior)HCC 9: Malignant Neoplasm of Head and Neck
C09.9Malignant neoplasm of tonsil, unspecifiedHCC 9: Malignant Neoplasm of Head and Neck
C06.2Malignant neoplasm of retromolar areaHCC 9: Malignant Neoplasm of Head and Neck
C10.2Malignant neoplasm of lateral wall of oropharynxHCC 9: Malignant Neoplasm of Head and Neck
C77.0Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neckHCC 8: Metastatic Cancer and Acute Leukemia

Procedural Details

Includes

The following components are considered an integral part of the procedure and are not billed separately:

  • Surgical exposure of the oropharynx.
  • Identification and protection of major vessels (e.g., carotid artery) and nerves.
  • The complete excision of the tumor with margins.
  • Control of bleeding (hemostasis).
  • A standard tonsillectomy is inherently included.

Excludes

The following procedures are more extensive and, if performed, may be billed separately. Always check NCCI (National Correct Coding Initiative) edits.

  • Closure: If the surgeon closes the defect (e.g., with a local flap), you must use 42841 instead. Do not bill 42840 and a closure code together.
  • Neck Dissection: If the cancer has spread to the lymph nodes in the neck, a neck dissection is often performed. This is separately reportable.
  • Tracheostomy: If a temporary or permanent tracheostomy is required for airway management.
  • Glossectomy: Partial or total removal of the tongue, if the tumor extends into it.
  • Mandibulectomy: Removal of part of the jawbone, if the tumor invades the mandible.

CPT Code Tree

  • Surgery
    • Digestive System (40490-49999)
      • Pharynx, Adenoids, and Tonsils (42700-42999)
        • Excision and Destruction
          • …
          • 42826 - Tonsillectomy, primary or secondary; age 12 or over
          • …
          • 42840 - Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure
          • 42841 - Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; with closure

Clinical Coding Examples

Example 1: Isolated Tonsil Cancer

  • Scenario: A 62-year-old patient is diagnosed with squamous cell carcinoma confined to the left tonsillar fossa. The surgeon performs a radical resection of the left tonsil, tonsillar pillars, and a small portion of the retromolar trigone. The resulting defect is packed and left open to granulate.
  • CPT Code: 42840-LT
  • ICD-10 Code: C09.0 (Malignant neoplasm of tonsillar fossa)

Example 2: Cancer with Neck Metastasis

  • Scenario: A 55-year-old patient has a large tumor on the right tonsil that extends to the posterior pillar. A pre-operative CT scan shows suspicious lymph nodes in the right neck. The surgeon performs a radical resection of the right tonsil and pillars, leaving the wound open. In the same operative session, the surgeon also performs a modified radical neck dissection to remove the cancerous lymph nodes.
  • CPT Codes:
    • 42840-RT
    • 38724-RT, -51 (Modified radical neck dissection with modifier 51 for multiple procedures)
  • ICD-10 Codes:
    • C09.1 (Malignant neoplasm of tonsillar pillar)
    • C77.0 (Secondary malignant neoplasm of lymph nodes of head, face and neck)

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