2025 CPT code 42100
Biopsy of palate, uvula. This procedure involves the removal of tissue from the palate or uvula for pathological analysis.
Modifiers may be applicable to this code. Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity for this procedure must be established by documenting the clinical signs, symptoms, or history suggesting a need for the biopsy.This could include a suspicious lesion, persistent pain, difficulty swallowing, or a history of cancer.
The physician is responsible for prepping and anesthetizing the patient, making the incision, taking the tissue sample, sending it to pathology, flushing the site, and applying antibiotics.
In simple words: A small tissue sample is taken from the roof of your mouth or the dangling tissue at the back of your throat.This sample is then sent to a lab to be examined for any abnormalities.
The physician performs a biopsy by making an elliptical incision around the affected tissue in the palate (roof of the mouth) or the uvula (fleshy body at the back of the mouth). A sample of the affected tissue is taken using a scalpel and sent to pathology for analysis. The site is then flushed with saline solution and antibiotics are applied.
Example 1: A patient presents with a suspicious lesion on the soft palate. A biopsy is performed using code 42100 to determine the nature of the lesion., A patient with an enlarged uvula causing snoring undergoes a uvula biopsy (42100) to rule out any underlying pathology before considering uvulectomy., A patient with a history of oral cancer undergoes a routine palate biopsy (42100) for surveillance and early detection of recurrence.
Documentation should include the location of the biopsy (palate or uvula), the size and description of the lesion (if present), the method of biopsy, and any complications. The pathology report should also be included in the patient's medical record.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- Payment Status: Active
- Specialties:Otolaryngology (ENT)
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center