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42842

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CPT 42842: Radical Resection of Tumor; Pharynx

Detailed Description

CPT code 42842 describes the surgical procedure for a radical resection of a malignant tumor located in the pharynx. The pharynx is the part of the throat behind the mouth and nasal cavity, and above the esophagus and larynx. This procedure is performed primarily for large or invasive cancers of the oropharynx, hypopharynx, or nasopharynx.

The term “radical resection” implies that the surgery is extensive. The surgeon removes the tumor along with a wide margin of surrounding healthy tissue to ensure all cancerous cells are eradicated. Depending on the tumor’s size and location, this may involve removing parts of the soft palate, the base of the tongue, the tonsils, or the walls of the pharynx. The goal is complete oncologic removal, which often results in a significant surgical defect that may require reconstruction (which is billed separately).

This is a major head and neck surgical procedure performed under general anesthesia, typically requiring an inpatient hospital stay.

Key Coding Information

  • wRVU: 27.65 (Note: wRVU values are subject to change annually based on the CMS Physician Fee Schedule).
  • Assistant at Surgery: Payable. This is a complex procedure where an assistant surgeon is often medically necessary. An appropriate modifier (-80, -81, -82, or -AS) may be used.
  • Global Period: 90 days. All typical, related pre-operative and post-operative care provided by the surgeon is included in the payment for the surgery.
  • MS-DRG (Inpatient): This procedure will typically group to one of the following DRGs, depending on the presence of comorbidities or complications:
    • MS-DRG 146: Major Head and Neck Procedures with Major Complication or Comorbidity (MCC)
    • MS-DRG 147: Major Head and Neck Procedures with Complication or Comorbidity (CC)
    • MS-DRG 148: Major Head and Neck Procedures without CC/MCC

Code Tree (Hierarchical Context)

  • Surgery
    • Digestive System (40490-49999)
      • Pharynx, Adenoids, and Tonsils (42700-42999)
        • Excision / Resection
          • 42820 - Tonsillectomy and adenoidectomy, younger than age 12
          • …
          • 42842: Radical resection of tumor; pharynx
          • 42844: Radical resection of tumor; pharynx, with radical neck dissection
          • 42845: Radical resection of tumor; pharynx, with reconstruction

Includes (Bundled Services)

The following services are considered an integral part of 42842 and are not separately billable:

  • The surgical approach to access the pharynx (e.g., transoral, pharyngotomy).
  • Identification and preservation of vital neurovascular structures.
  • The complete excision of the pharyngeal tumor with planned margins.
  • Minor vessel ligation and control of bleeding (hemostasis).
  • Simple or direct closure of the pharyngeal defect.
  • Placement of drains.

Excludes (Separately Reportable Services)

42842 describes the pharyngeal resection only. The following common procedures are not included and should be billed separately if performed:

  • Radical Neck Dissection: If a neck dissection is performed at the same session, do not use 42842 + 38724. Instead, use the combination code 42844.
  • Reconstruction: If reconstruction of the pharyngeal defect is performed (e.g., with a local, regional, or free flap), do not use 42842 alone. Use the comprehensive code 42845. If a different surgeon performs the reconstruction, they would bill their respective flap code (e.g., 15756 for a free flap).
  • Tracheostomy: If a tracheostomy is performed to secure the airway, it is separately reportable with CPT code 31600.
  • Gastrostomy Tube (G-tube): Placement of a feeding tube is common and is billed separately (e.g., 49440 for percutaneous placement).
  • Diagnostic Scopes: A diagnostic laryngoscopy or esophagoscopy performed during the same session to evaluate the extent of the tumor is typically bundled. However, if it’s a distinct, separate procedure, it may be billable with an appropriate modifier like 59.

Common ICD-10-CM Diagnosis Pairing

This procedure is used to treat malignant neoplasms. The choice of code should be as specific as possible to the tumor’s location.

ICD-10 CodeDescriptionHCC CodeHCC Category
C10.9Malignant neoplasm of oropharynx, unspecifiedHCC 9Malignant Neoplasms of the Head and Neck
C10.2Malignant neoplasm of lateral wall of oropharynxHCC 9Malignant Neoplasms of the Head and Neck
C11.1Malignant neoplasm of posterior wall of nasopharynxHCC 9Malignant Neoplasms of the Head and Neck
C12.9Malignant neoplasm of pyriform sinusHCC 9Malignant Neoplasms of the Head and Neck
C13.9Malignant neoplasm of hypopharynx, unspecifiedHCC 9Malignant Neoplasms of the Head and Neck
C14.0Malignant neoplasm of pharynx, unspecifiedHCC 9Malignant Neoplasms of the Head and Neck

Coding Examples

Example 1: Standard Procedure

  • Scenario: A 62-year-old patient with a T3 squamous cell carcinoma of the right lateral pharyngeal wall undergoes a radical resection of the tumor via a transoral approach. The defect is closed primarily. No neck dissection or flap reconstruction is performed. A prophylactic tracheostomy is placed.
  • CPT Coding:
    • 42842: For the radical resection of the pharyngeal tumor.
    • 31600: For the separately performed tracheostomy.
  • ICD-10-CM Coding:
    • C10.2: Malignant neoplasm of lateral wall of oropharynx.

Example 2: Procedure with Neck Dissection

  • Scenario: A 55-year-old patient has a large tumor at the base of the tongue extending into the oropharynx, with clinically positive lymph nodes in the neck. The surgeon performs a radical resection of the pharyngeal tumor and a modified radical neck dissection on the same side.
  • Incorrect Coding: 42842 + 38724 (Radical Neck Dissection)
  • Correct Coding:
    • 42844: This single code bundles the radical pharyngectomy and the radical neck dissection. Using the component codes separately would be unbundling.
  • ICD-10-CM Coding:
    • C01.9: Malignant neoplasm of base of tongue, unspecified.
    • C77.0: Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck.

Example 3: Procedure with Complex Reconstruction by a Second Surgeon

  • Scenario: A patient undergoes a radical pharyngectomy by an ENT surgeon, which results in a very large defect. A plastic surgeon is present and immediately performs a radial forearm free flap to reconstruct the pharynx.
  • Coding for ENT Surgeon:
    • 42842: For the tumor resection. (The ENT surgeon did not perform the reconstruction).
  • Coding for Plastic Surgeon:
    • 15757: Free skin flap with microvascular anastomosis (or another appropriate free flap code).
    • Modifier 59 (Distinct Procedural Service) and/or 62 (Two Surgeons) may be necessary depending on payer guidelines.
  • ICD-10-CM Coding:

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