AHA Coding Clinic® for HCPCS - 2025 Issue 1; Ask the Editor

Release palatoglossal arch

A patient developed scar tissue post-tonsillectomy, tethering forward movement of the tongue on both sides. The most symptomatic side is the right side with scar tissue of the palatoglossal arch. The left side is less symptomatic. The patient is admitted for release of the palatoglossal arch on the right side. General tracheal anesthesia was administered, the tongue was retracted and placed in suspension. The palatoglossal arch was tethered on both sides with the right being higher than the left. The palatoglossal region was injected with 4 cc of 1% lidocaine with epinephrine. A scalpel was utilized to take down the scar tissue removing a wedge of tissue along the palatoglossal junction, releasing the tongue and palate to move upward. After injecting the palatoglossal arch on both sides with 0.5 cc of Kenalog 40, the area was cauterized achieving hemostasis. The retractor was taken out of suspension and removed. Our facility considered CPT codes 41599 or 42299; however, we were not sure which code to report considering both the tongue and the palate were released. How is the release of the palatoglossal arch coded? ...

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