Resolved Surgery Question

[DonnaA_43539]

Op Report:: A sweetheart retractor was used to retract the tongue and to the left hand side of the mouth and exposing the Right Retromolar trigone where there was a Keratotic leukoplakic lesion. 1. This area was injected with lidocaine and epiephrine hemostasis. Following this using a needle tip cautery the lesion was excised en bloc with a 5 mm margin around the lesion down to the underlying mandible. The specimen was removed and given to pathology for frozen section with a Suture place at the 12 o'clock position. Path came back benign Keratosis. 2. There was a second lesion on the anterior inferior mandible gingiva on the right that was Excised using the needle tip cautery and sent to pathology.The resulting defects were closed using interrupted suture.

Physician wants 42844 --excision of right retromalor trigone leukoplakia/hyperkeratosis with local flap closure
and 21047--excision of right mandibular alveolar ridge lesion with primary closure

i am looking at 21040 for second lesion and am confused about first lesion. There was not a Flap closure done so do not agree with code 42844.
Please Help!!

 

[Darcy]

You're absolutely right to question the use of CPT code 42844. This code specifically refers to a radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone with closure using a local flap. Since the operative report does not mention a flap closure, 42844 may not be the most appropriate choice.

For the second lesion, CPT code 21040 is used for the excision of a benign tumor or cyst of the mandible by enucleation and/or curettage. If the lesion was benign and did not require an osteotomy or partial mandibulectomy, 21040 seems like a more accurate choice than 21047, which is used when an extra-oral osteotomy and partial mandibulectomy are required.

It might be worth discussing with the physician whether a different code better reflects the procedure performed on the retromolar trigone lesion, given that no flap closure was documented. If the excision was extensive but did not involve a flap, another excision code may be more appropriate.

 

[DonnaA_43539]

You're absolutely right to question the use of CPT code 42844. This code specifically refers to a radical resection of the tonsil, tonsillar pillars, and/or retromolar trigone with closure using a local flap. Since the operative report does not mention a flap closure, 42844 may not be the most appropriate choice.

For the second lesion, CPT code 21040 is used for the excision of a benign tumor or cyst of the mandible by enucleation and/or curettage. If the lesion was benign and did not require an osteotomy or partial mandibulectomy, 21040 seems like a more accurate choice than 21047, which is used when an extra-oral osteotomy and partial mandibulectomy are required.

It might be worth discussing with the physician whether a different code better reflects the procedure performed on the retromolar trigone lesion, given that no flap closure was documented. If the excision was extensive but did not involve a flap, another excision code may be more appropriate.

Thanks so much for quick response! Appreciate the Guidance!

 

[DonnaA_43539]

Any idea what cpt to use on the 1st lesion?

 

[Darcy]

Any idea what cpt to use on the 1st lesion?

Based on the procedure described, the most relevant CPT code for the excision of a keratotic leukoplakic lesion in the retromolar trigone with frozen section pathology and a benign keratosis diagnosis could be 41826. This code is used for the excision of benign lesions in the oral cavity, including the retromolar trigone.

 

[DonnaA_43539]

great! that is the one i was leaning towards also.. Thanks Again