AHA Coding Clinic® for HCPCS - 2024 Issue 2; Ask the Editor

Tonsillectomy with expansion sphincteroplasty

A patient over the age of 12, with obstructive sleep apnea presents for bilateral tonsillectomy and expansion sphincteroplasty. The right tonsil was grasped with a tenaculum and retracted from the tonsillar fossa. It was then dissected free from the surrounding pharyngeal musculature from a superior to inferior fashion using electrocautery. The left tonsil was removed in the same fashion. The sphincteroplasty portion of the procedure was then started. A 12 Fr red rubber catheter was passed along the right nasal passage and pulled through the oropharynx to retract the soft palate. A dental mirror was used to visualize the nasopharynx and the structures were normal. The palatoglossus muscle was visualized and transected inferiorly. It was released in an inferior to superior direction until the upper oropharynx was reached. The muscle was sutured to the hook of the hamulus with 3-0 Vicryl and this was also performed on the contralateral side. The inferior aspects of the pillars were closed with 3-0 Vicryl. The superior pillar was not closed. The inferior aspect of the uvula was resected, and the mucosal edges were re approximated with 3-0 Vicryl. The physician in this case identified the procedure as an expansion sphincteroplasty. However, there are other names used such as expansion sphincter pharyngoplasty or a lateral pharyngoplasty to describe this procedure. What is the correct code(s) to capture the expansion sphincteroplasty with bilateral tonsillectomy? ...

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