Summary & Overview
CPT 42145: Palatopharyngoplasty (uvulopalatopharyngoplasty)
CPT code 42145 designates palatopharyngoplasty, a surgical procedure (including uvulopalatopharyngoplasty and uvulopharyngoplasty) performed to widen the oropharyngeal airway, commonly used in treating obstructive sleep apnea. Nationally, this code is important because surgical airway interventions remain a key treatment pathway when noninvasive therapies are ineffective or not tolerated. Payers commonly involved in coverage and payment decisions for this procedure include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
This publication provides a concise briefing on clinical context, typical settings of care, and the payer landscape affecting use of CPT code 42145. Readers will find benchmarks for utilization and payment where available, summaries of common policy themes (medical necessity criteria and site-of-service considerations), and explanations of how the procedure is reported administratively. The report also outlines practical coding context for clinicians and billing staff, including typical modifiers and billing considerations. Data not available in the input is identified explicitly where relevant. The goal is to inform hospital administrators, surgical teams, and revenue-cycle professionals about the coding and coverage environment for palatopharyngoplasty at a national level.
Billing Code Overview
CPT code 42145 describes palatopharyngoplasty, including procedures such as uvulopalatopharyngoplasty and uvulopharyngoplasty, performed to widen the oropharyngeal airway. The procedure is typically used in the surgical management of obstructive sleep apnea and related upper airway obstruction.
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Service type: Surgical procedure to modify oropharyngeal anatomy and enlarge the airway
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Typical site of service: Ambulatory surgical center or hospital operating room
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with obstructive sleep apnea (OSA) who has persistent symptoms despite positive airway pressure therapy or is intolerant of CPAP. The patient presents to an otolaryngology clinic with loud snoring, witnessed apneas, excessive daytime sleepiness, and an abnormal sleep study (polysomnography) showing moderate to severe OSA. Prior to surgery, the workflow includes a preoperative evaluation with airway assessment, review of prior sleep study results, medical clearance (cardiac and pulmonary risk assessment), and documentation of failed conservative treatments (weight loss attempts, oral appliance trials, or CPAP intolerance). On the day of service, the patient undergoes general anesthesia in an ambulatory surgical center or hospital operating room. The surgeon performs a palatopharyngoplasty (for example, 42145 uvulopalatopharyngoplasty) to widen the oropharyngeal airway by resecting/repositioning redundant palatal and pharyngeal tissues. Postoperative care includes airway observation in PACU, pain control, swallow evaluation if indicated, and follow-up for wound healing and assessment of sleep symptoms and repeat polysomnography when clinically appropriate.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When work, time, and intensity substantially exceed the usual for 42145 due to extensive scarring or complexity |