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CPT Code for Radiofrequency Palatoplasty

Deanna Posted Mon 03rd of February, 2014 16:41:48 PM

Could you please help me with the following in-office procedure? Diagnosis used was: obstructive sleep apnea and snoring. Thanks in advance!

After appropriate consent, topical anesthetic was applied to the soft palate in the form of 20% benzocaine ointment. A total of 6 cc of a 1:1 mixture of 2% Lidocaine with epinephrine and sodium bicarb was injected into the soft palate. After allowing adequate time for anesthetic effect, the Coblation device was used to create four lesions in the soft palate, each of 15 second durations, located in the mid point of the palate, 1 cm laterally and also in the uvula itself. Patient tolerated the procedure well, no blood loss. Instructions given.

SuperCoder Answered Tue 04th of February, 2014 15:47:15 PM

For RFA of the palate, uvula, you should use 42299 (Unlisted procedure, palate, uvula). CPT® guidelines maintain that no other CPT® code fits appropriately to describe RFA of the palate or uvula, and debunk the option of using the uvulopalatopharyngoplasty code 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) appended by modifier 52 (Reduced services). You cannot use 42145 (or 42145-52) because this code represents an excisional removal of the uvula and palate, and the laser ablation (or reduction in size) does not meet the guidelines for an excisional removal as necessary for 42145. Additionally, CMS has indicated that they do not consider a LAUP or a RFA of the uvula or palate standards of care and consider them experimental. The only way a payer can differentiate a LAUP and RFA of the palate and uvula is by using the unlisted code and disallowing the excisional code, 42145, for these alternative methods of getting the palate and/or the uvula out of the way of the airway.

Furthermore, you should not confuse laser-assisted uvulopalatoplasty (LAUP), which you should also report with 42299, with uvulopalatopharyngoplasty.

Rationalization: An outpatient treatment for snoring and mild forms of sleep apnea, LAUP (42299) involves a laser which the physician uses to vaporize part of the uvula, a small triangular piece of tissue that hangs from the soft palate above the back of the tongue. On the other hand, uvulopalatopharyngoplasty (42145) involves removing the uvula (and sometimes the tonsils), trimming the soft palate, and suturing all cut edges together. Physicians perform this surgical operation under general anesthesia in a hospital setting.

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