I am struggling finding the approprate code for a lateral pharyngectomy without closure. I jumped to 42890. However, the surgeons apporach was oral and not through the neck.
OP Note:
"I did initially palpate the oropharynx and this was difficult because of her small mouth, but there was a firmness to the left tonsil I felt when compared to the right, although on inspection, obviously these were 1-2+ tonsils and there was no obvious tumor mass noted.
I did of course use a McIvor retractor throughout the case and I used a red rubber tube to retract the soft palate which was intact. I did go ahead and do the left lateral pharyngectomy with a Bovie dissection technique and, as stated previously, I went into a deeper plane in case there was evidence of malignancy in the tonsil. I took some of the surrounding musculature along with the entire tonsil. I did this very carefully. We had minimal bleeding. This went beautifully. I was able to remove the specimen without any problems and marked this with a suture inferiorly for orientation for the pathologist. This was sent in formalin for permanent section. I then simply assured hemostasis and injected with 0.25% Marcaine throughout the left lateral pharyngectomy defect to make sure we had good pain control postoperatively. She was allowed to recovery from the anesthetic and was escorted to the recovery room having had minimal bleeding and no problems. Obviously I elected not to remove the right tonsil and hopefully this will help with her postop p.o. intake."
OP Note:
"I did initially palpate the oropharynx and this was difficult because of her small mouth, but there was a firmness to the left tonsil I felt when compared to the right, although on inspection, obviously these were 1-2+ tonsils and there was no obvious tumor mass noted.
I did of course use a McIvor retractor throughout the case and I used a red rubber tube to retract the soft palate which was intact. I did go ahead and do the left lateral pharyngectomy with a Bovie dissection technique and, as stated previously, I went into a deeper plane in case there was evidence of malignancy in the tonsil. I took some of the surrounding musculature along with the entire tonsil. I did this very carefully. We had minimal bleeding. This went beautifully. I was able to remove the specimen without any problems and marked this with a suture inferiorly for orientation for the pathologist. This was sent in formalin for permanent section. I then simply assured hemostasis and injected with 0.25% Marcaine throughout the left lateral pharyngectomy defect to make sure we had good pain control postoperatively. She was allowed to recovery from the anesthetic and was escorted to the recovery room having had minimal bleeding and no problems. Obviously I elected not to remove the right tonsil and hopefully this will help with her postop p.o. intake."