In simple words: This procedure repairs a tear at the junction of the throat and the esophagus. Sometimes, a muscle flap from the neck is used to strengthen the repair.

Surgical reconstruction of a perforation (caused by injury) in the pharyngeal-esophageal intersection. The repair may involve a sternocleidomastoid muscle flap technique. This code does not include closure with myocutaneous or other flaps; if used, an additional code should be reported.

Example 1: A patient presents with a pharyngoesophageal perforation following instrumentation during an upper endoscopy. The surgeon performs a primary repair of the perforation using 42953., A patient sustains a penetrating neck injury that results in a pharyngoesophageal perforation. Due to the size and complexity of the injury, the surgeon utilizes a sternocleidomastoid muscle flap to reinforce the repair, reporting 42953 and an additional code for the flap., A patient with a history of prior neck surgery develops a pharyngoesophageal fistula. The surgeon performs a complex repair of the fistula using a regional flap, reporting 42953 along with a code for the flap reconstruction.

Documentation should include details of the perforation (size, location, cause), the repair technique used, and any associated procedures like flap reconstruction. Operative reports, pre- and post-operative notes, and imaging studies should be maintained.