Wiki Need Help with parapharyngeal abscess!

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AN2114

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Doctor said he did a procedure for incision and drainage of parapharyngeal abscess. But in the procedure details it says there was no drainage and no abscess found. Below is the op report:

Procedure: Incision and drainage of parapharyngeal abscess

Procedure details: Patient was taken to surgery induced with general anesthesia and intubated. Shoulder roll was placed to provide neck extension. Patient was then properly prepped and draped. McIvor mouth gag was inserted into the mouth and patient was suspended from the Mayo stand. The palate was suspended using red rubber catheters. Swelling was noted on the left pharyngeal wall. An incision was made here and dissection was done using a hemostat. A cavity was developed with no purulence expressed. An incision was then made more superior in the palate, dissection was completed using a hemostat, again with no purulent drainage noted. The area was widely dissected and after thorough examination, there was no abscess able to be found. Hemostasis was confirmed. All instrumentation was removed and patient was sent to recovery in satisfactory condition.

I don't know what to do about the cpt code. Should I still use 42720? Or is there a better code to use based on this op note?
 
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Regardless that no abscess was found or pus expressed your physician did perform the intended surgery due to the obvious swelling and the clinical indicators. This is one of the gray coding moments and if you are not certain you should bill 42720 than you should stick to the unlisted procedure code 42999 - Unlisted procedure pharynx, adenoids, or tonsils as there are no exploratory codes available for the parapharyngeal area. Also, another consideration is to append a modifier 52 - Reduced Services to 42720 due to the lack of findings, again, that would be your and your physicians call.
 
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jackjones62 said:
Regardless that no abscess was found or pus expressed your physician did perform the intended surgery due to the obvious swelling and the clinical indicators. This is one of the gray coding moments and if you are not certain you should bill 42720 than you should stick to the unlisted procedure code 42999 - Unlisted procedure pharynx, adenoids, or tonsils as there are no exploratory codes available for the parapharyngeal area. Also, another consideration is to append a modifier 52 - Reduced Services to 42720 due to the lack of findings, again, that would be your and your physicians call.
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thank you!
 
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