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    v1.0.28
    OpenPayerBilling CodesExcision and Destruction Procedures on the Pharynx, Adenoids, and TonsilsCPT cpt-42894-pharyngeal-wall-pyriform-sinus-reconstruction-flap
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    CPT 42894: Partial Pharyngeal Wall or Pyriform Sinus Resection with Flap Closure

    Medicare pays $2118 on average nationally for this procedure.

    CPT code 42894 describes a surgical procedure that removes part of the pharyngeal wall or pyriform sinus with wound closure using a myocutaneous, fasciocutaneous, free muscle, skin, or fascial flap; this represents a reconstructive head and neck surgery typically performed in an operating room setting as a major surgical service for management of neoplastic or traumatic defects of the hypopharynx and adjacent structures.

    For related coverage guidance, see recent payer policy updates: Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders, Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders, Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders.

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    Table of contents

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient is a 58-year-old male with a squamous cell carcinoma of the hypopharynx involving the pyriform sinus and adjacent pharyngeal wall. After staging workup (contrast CT, PET-CT, flexible endoscopy) and multidisciplinary tumor board review, the patient is scheduled for wide local excision of the involved pharyngeal wall and partial resection of the pyriform sinus for oncologic clearance. During the operative workflow, the head and neck surgeon performs en bloc resection of the tumor with negative margins, assesses defects, and reconstructs the resultant pharyngeal and hypopharyngeal defect using a myocutaneous or fasciocutaneous pedicled flap (for example, pectoralis major myocutaneous flap) or a free tissue transfer (for example, radial forearm free flap) to restore pharyngeal continuity and protect the airway. Intraoperative steps include direct laryngoscopy or suspension microlaryngoscopy for visualization, neck dissection if indicated, flap inset and microvascular anastomosis if a free flap is chosen, layered closure, and placement of feeding access (eg, nasogastric or gastrostomy) when required. Postoperative care includes ICU or step-down monitoring for airway compromise and flap viability, swallow evaluation, speech and swallow therapy, and adjuvant radiation or chemoradiation as indicated by pathology.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    31575Laryngoscopy, direct; with excision of lesion(s) of the larynx, with or without mucosal resectionUsed for diagnostic/excisional access or synchronous laryngeal lesions requiring direct laryngoscopic management prior to or during pharyngeal resection.
    31599Unlisted procedure, larynxMay be used for procedures not otherwise specified in the larynx/hypopharynx region when no more specific code applies.
    20926Muscle, myocutaneous or fasciocutaneous flap; trunkDescribes regional pedicled flap harvest and can be billed when separate flap codes are required in reconstruction of pharyngeal defects.
    15756Muscle, myocutaneous or fasciocutaneous flap; forearm or handApplicable when radial forearm free flap harvest is performed for pharyngeal reconstruction.
    20938Free flap with microvascular anastomosisUsed when free tissue transfer with microvascular anastomosis is performed for reconstruction following resection.

    Related Modifiers

    9 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    66Modifier 66 (Surgical Team) is used when three or more surgeons act as primary surgeons on a single, highly complex procedure. The AMA defines it for use when a surgical team — often composed of…- Use modifier 66 when three or more surgeons act as primary surgeons working collaboratively as a surgical team on a single, highly complex or difficult procedure (for example organ…
    76Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…
    80CPT® Modifier 80 (Assistant Surgeon) is appended to a surgical CPT code when a physician (MD or DO) provides full, continuous assistance throughout the operative procedure. It is intended only for…- Use CPT Modifier -80 when a physician (MD or DO) serves as an assistant surgeon and provides full, continuous assistance throughout the entire operative procedure; append -80 to the surgical CPT…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    208M00000XHospitalist PhysicianHospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient ca…
    2080P0205XPediatric Endocrinology PhysicianA pediatrician who provides expert care to infants, children and adolescents who have diseases that result from an abnormality in the endocrine glands…
    2084P0800XPsychiatry PhysicianA Psychiatrist specializes in the prevention, diagnosis, and treatment of mental disorders, emotional disorders, psychotic disorders, mood disorders, …
    207L00000XAnesthesiology PhysicianAn anesthesiologist is trained to provide pain relief and maintenance, or restoration, of a stable condition during and immediately following an opera…
    2086S0122XPlastic and Reconstructive Surgery PhysicianA surgeon who specializes in plastic and reconstructive surgery.
    332100000XDepartment of Veterans Affairs (VA) PharmacyDepartment of Veterans Affairs (VA) Pharmacy means any place under VA jurisdiction where drugs are dispensed and Pharmaceutical Care is provided to en…
    207VC0300XComplex Family Planning PhysicianA complex family planning physician specializes in the diagnosis and treatment of individuals with complex reproductive needs. These physicians are ex…
    2080B0002XPediatric Obesity Medicine PhysicianA physician who specializes in the treatment of obesity demonstrates competency in and a thorough understanding of the treatment of obesity and the ge…

    Related ICD-10-CM Codes

    27 rows

    ICD-10-CM CodeDescription
    B97.0Adenovirus as the cause of diseases classified elsewhere
    C06.9Malignant neoplasm of mouth, unspecified
    C09.0Malignant neoplasm of tonsillar fossa
    C09.1Malignant neoplasm of tonsillar pillar (anterior) (posterior)
    C10.0Malignant neoplasm of vallecula
    C10.2Malignant neoplasm of lateral wall of oropharynx
    C13.0Malignant neoplasm of postcricoid region
    C13.1Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect
    C13.9Malignant neoplasm of hypopharynx, unspecified
    C14.8Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

    Showing 1–10 of 27

    Related Payer Policy Updates

    Specialty: Anesthesiology1 / 3

    9 rows

    PolicyPayerEffective Date
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use DisordersPremera Bluecross2026-07-01
    Elective Inpatient Services (for Idaho Only)UnitedHealthcare2026-06-01
    Sites of Servicepriority health2026-06-01
    Coverage for Ambulatory Surgery Unit (ASU)/Outpatient Facility and Anesthesia for Dental Servicesuniverahealthcare2026-05-21
    Mm_0579_Coveragepositioncriteria_Anesthesia_Services_Selected_Nerve_BlocksCigna2026-05-15
    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric DisordersBlue Cross Blue Shield - North Carolina2026-04-01

    Related Codes

    CPT-42800-OROPHARYNGEAL-BIOPSY

    CPT 42800: Biopsy, Oropharynx

    CPT-42804-NASOPHARYNGEAL-LESION-BIOPSY

    CPT 42804: Biopsy of Visible Nasopharyngeal Lesion

    CPT-42806-NASOPHARYNGEAL-BIOPSY-UNKNOWN-PRIMARY-LESION

    CPT 42806: Biopsy of Nasopharyngeal Lesion, Unknown Primary

    CPT-42808-PHARYNGEAL-LESION-DESTRUCTION-LASER-CRYOSURGERY

    CPT 42808: Pharynx Lesion Destruction (Laser, Cryosurgery, Electrocautery)

    CPT-42809-PHARYNX-FOREIGN-BODY-REMOVAL

    CPT 42809: Removal of Foreign Body from Pharynx

    CPT-42810-BRACHIAL-CLEFT-CYST-EXCISION

    CPT 42810: Excision of Brachial Cleft Cyst, Lateral Neck

    CPT-42815-BRACHIAL-CLEFT-CYST-EXCISION

    CPT 42815: Excision of Brachial Cleft Cyst, Lateral Neck

    CPT-42820-TONSILLECTOMY-AND-ADENOIDECTOMY-YOUNGER-THAN-12

    CPT 42820: Tonsillectomy and Adenoidectomy, Patient Younger Than 12 Years

    CPT-42821-TONSILLECTOMY-ADENOIDECTOMY-AGE-12-PLUS

    CPT 42821: Tonsillectomy with Adenoidectomy, Age 12 or Older

    CPT-42825-PEDIATRIC-TONSILLECTOMY-UNDER-12

    CPT 42825: Tonsillectomy in Patients Under 12 Years

    Showing 1–10 of 22

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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