CPT 42955 Pharyngostomy Reimbursement & Policy | OpenPayer

Summary & Overview

CPT 42955: Pharyngostomy for Long-Term Enteral Feeding

CPT code 42955 represents a surgical pharyngostomy procedure to create an artificial opening in the pharynx for long-term enteral feeding. This procedure is clinically important for patients who cannot maintain adequate oral nutrition due to obstructive, neurologic, or structural disorders. Nationally, it is relevant to acute-care surgical services, nutrition support programs, and discharge planning for patients requiring prolonged enteral access.

Key payers in the scope of this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides an overview of clinical context, typical sites of service, and payer coverage considerations. Readers will find benchmarks for utilization and reimbursement patterns, policy updates affecting coverage and prior authorization practices, and clinical considerations that influence coding and care pathways.

The report also outlines common billing modifiers and how they interact with procedure reporting, operational considerations for hospitals and ambulatory surgical centers, and areas where policymakers and payers frequently set limits or criteria for coverage. Data not available in the input is noted explicitly where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare42955CPTpharyngostomyenteral-feedingsurgical-procedurenutrition-supportoperating-roomambulatory-surgery

Billing Code Overview

CPT code 42955 describes a surgical procedure in which the physician creates an artificial opening in the pharynx for long-term feeding. This procedure establishes a direct access route to the upper digestive tract to facilitate nutritional support when oral intake is not possible or adequate.

Service type: Surgical procedure for long-term enteral access
Typical site of service: Hospital operating room or ambulatory surgical center

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with chronic dysphagia and risk of aspiration due to neurologic disease (for example advanced stroke, amyotrophic lateral sclerosis, or Parkinson disease) who requires long‑term enteral nutrition. The patient is evaluated by a multidisciplinary team (otolaryngology or general surgery, speech‑language pathology, nutrition, and nursing). After goals of care discussion and assessment that percutaneous or endoscopic gastrostomy is contraindicated or not feasible, the physician schedules a surgical pharyngostomy to create a durable opening in the pharynx for long‑term feeding access. The procedure is performed in an operating room under general anesthesia or monitored anesthesia care. Intraoperative steps include exposure of the pharyngeal wall, creation of a stoma, maturation of the opening to the skin, and placement of a feeding tube or stoma appliance. Postoperative workflow includes recovery room monitoring, confirmation of tube position and function, initiation of appropriate tube feeding protocols, wound care instructions, and outpatient follow‑up with the surgical team and nutrition services.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work or complexity substantially exceeds typical for the procedure (document increased work).
`52`

CPT 42961: Control of Postoperative Oropharyngeal Bleeding, Inpatient

CPT-42971-NASOPHARYNGEAL-BLEEDING-CONTROL-POST-ADENOIDECTOMY

CPT 42971: Inpatient Control of Postoperative Nasopharyngeal Bleeding

CPT-42972-NASOPHARYNGEAL-BLEEDING-CONTROL-POST-ADENOIDECTOMY

CPT 42972: Surgical Control of Postoperative Nasopharyngeal Bleeding

CPT-42962-POSTOPERATIVE-ORAL-PHARYNGEAL-HEMOSTASIS

CPT 42962: Postoperative Oral and Pharyngeal Hemostasis

CPT-42970-POSTOP-NASOPHARYNGEAL-BLEEDING-CONTROL

CPT 42970: Simple Control of Postoperative Nasopharyngeal Bleeding

CPT-42960-OROPHARYNGEAL-BLEEDING-CONTROL-POSTOPERATIVE

CPT 42960: Control of Postoperative Oropharyngeal Bleeding

CPT-42975-ENDOSCOPIC-AIRWAY-EVALUATION-SLEEP-DISORDERED-BREATHING

CPT 42975: Endoscopic Airway Evaluation During Sedation

CPT-42999-UNLISTED-PHARYNX-ADENOIDS-TONSILS-PROCEDURE

CPT 42999: Unlisted Pharynx, Adenoids, or Tonsils Procedure

Taxonomy Code	Specialty	Notes
2080S00000X	General Surgery	General surgeons commonly perform open pharyngostomy procedures.
207ZP0006X	Otolaryngology (ENT)	ENT surgeons perform pharyngeal access procedures and stoma creation.
2086S0002X	Thoracic Surgery	Thoracic surgeons may be involved when airway or high pharyngeal access overlaps with thoracic procedures.
335E00000X	Gastroenterology	Gastroenterologists are involved when enteral access decisions and tube management overlap with GI care.
208C00000X	Critical Care Medicine	Critical care physicians coordinate perioperative care for medically complex patients.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`G12.21`	Amyotrophic lateral sclerosis	Progressive neuromuscular failure causing dysphagia and need for long‑term enteral access.
`I69.390`	Dysphagia following cerebral infarction	Post‑stroke swallowing dysfunction commonly necessitating durable feeding access.
`R13.10`	Dysphagia, unspecified	Symptom indicating impaired swallowing that may require surgical feeding access.
`G20`	Parkinson disease	Advanced disease can produce severe dysphagia and aspiration risk prompting pharyngostomy.
`C32.9`	Malignant neoplasm of larynx, unspecified	Head and neck cancers may obstruct oral intake or preclude gastrostomy, leading to pharyngostomy for feeding.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43246`	Esophagoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing	May be performed preoperatively to evaluate pharyngeal and esophageal anatomy prior to stoma creation.
`49440`	Insertion of percutaneous gastrostomy tube, under fluoroscopic guidance	Alternative long‑term enteral access method when pharyngostomy is not indicated or feasible.
`43760`	Open gastrostomy, without construction of gastric tube	May be performed when gastric access is chosen instead of pharyngostomy; part of decision tree for enteral nutrition.
`43761`	Replacement of gastrostomy tube under general anesthesia	Postoperative or subsequent management of enteral access devices; relevant when converting or replacing tubes placed via pharyngostomy.
`31500`	Intubation, endotracheal, emergency procedure	May be necessary for airway control during anesthesia for pharyngostomy in patients with compromised airway.

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