please read op note-would cpt code 42890 be inclusive or can it be billed separately.


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1. Transoral robotic assisted base of tongue resection, CPT 41130.
2. Limited right lateral pharyngectomy, CPT 42890.

DESCRIPTION OF PROCEDURE: The patient was identified in the preoperative
holding area and brought to the operating room. Time-out was performed
confirming correct patient, procedure, operative site, and positioning and
general endotracheal anesthesia was induced via nasal endotracheal
technique and the table was turned 180 degrees. The oropharynx was then
exposed by placing the FK retractor on suspension. Adequate visualization
was noted. The robotic side cart was docked and the camera and operative
arms were triangulated into the pharynx with good visualization. The
resection began with the anterior, medial, and lateral incisions. A cuff
of tongue musculature was kept on the underside of tumor as the resection
proceeded from anterior to posterior until laterally the hyoid bone was
identified and into the preepiglottic space to achieve the adequate
posterior deep margin. The orientation stitches were placed and the
specimen was taken to the frozen section room and margins were sent
directly from the primary specimen. The deep margin was assessed by the
pathology team by cutting through the primary specimen. All intraoperative
margins were negative. Hemostasis was confirmed with Valsalva maneuver.
The base of the epiglottis on the suprahyoid portion was then
reapproximated to the preepiglottic tissue with 2 interrupted Vicryl
stitches to re-suspend the epiglottis. The FK retractor was then taken off
suspension and removed and this completed the robotic resection portion of
the procedure. Of note, the right lateral pharyngeal wall was taken en
bloc with the primary specimen to obtain an adequate lateral margin.