General Surgery Coding Alert

Don’t miss the pathogen Dx code.

Tonsillectomy may be an everyday occurrence for general surgeons, but that doesn’t make it easy to correctly code the cases.

Look at the following brief diagnosis and procedure descriptions and try your hand at pinpointing the correct codes:

Procedure indications: Patient is a 10-year-old male with a history of tonsillitis who presented with a recent acute eight-day bout of painful sore throat with inflamed tonsils.

Procedure: Bilateral tonsillectomy

Procedure description: Following anesthesia induction, a Crowe-Davis mouth gag suspended the oropharynx to visualize the tonsils and palate. Forceps were used to free the right tonsil from the fibrous capsule, and a tonsil snare was placed around the inferior pole. The tonsil was removed and hemostasis achieved. Attention was turned to the left side and the procedure repeated. Tonsils were submitted to pathology with a request for infectious agent detection.

Final diagnosis: Tonsillitis due to H. influenzae infection

Focus Tonsillectomy Procedure Code Selection

A few factors add to the complexity of selecting the correct CPT^® code for tonsillectomy procedures. To help you choose the proper code, you should consider the following elements:

• Patient age;
• Whether the tissue had regrown following a previous removal procedure (primary or secondary);
• Whether the surgeon also removes adenoids; and
• Whether the surgeon also removes other associated tissue such as lymph nodes, and adjacent muscle.

You can see those factors at play in the following CPT^® code choices for this case:

• 42820 (Tonsillectomy and adenoidectomy; younger than age 12)
• 42821 (Tonsillectomy and adenoidectomy; age 12 or over)
• 42825 (Tonsillectomy, primary or secondary; younger than age 12)
• 42826 (Tonsillectomy, primary or secondary; age 12 or over)
• 42830 (Adenoidectomy, primary; younger than age 12)
• 42831 (Adenoidectomy, primary; age 12 or over)
• 42835 (Adenoidectomy, secondary; younger than age 12)
• 42836 (Adenoidectomy, secondary; age 12 or over)
• 42842 (Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure)
• 42844 (Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal))
• 42845 (Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap)

Choose: The documentation in this case states that the patient is 10 years old, and there is no mention of the surgeon removing any tissues other than the right and left tonsil. Also, there is no mention of whether the removal is secondary (following a prior tonsillectomy for regrowth or missed tissue) or primary. For that reason, the proper procedure code for this case is 42825.

Bilateral: The case documents that the surgeon removes the left and right tonsils. Does that mean you should bill 42825 with modifier 50 (Bilateral procedure)? No. Tonsillectomy and adenoidectomy codes 42820-42836 describe bilateral surgery. That said, if the surgeon removes a single tonsil and/or a single adenoid, you should bill the appropriate code with modifier 52 (Reduced services).

Pitfalls: When you face a tonsillectomy case that is more complex than this one, you have some coding snags to avoid. For instance, if the surgeon removes tonsils and adenoids, you must use one of the combination codes (42820 or 42821). Even if the documentation shows the procedure involves a secondary adenoidectomy, you should not report a tonsillectomy code such as 42825 with the related secondary adenoidectomy code, 42835. National Correct Coding Initiative (NCCI) edits bundle the related tonsillectomy/adenoidectomy codes with a modifier indicator “0,” meaning that you can never override the edit pairs.

Drill Down to Details for Correct Diagnosis Coding

The first decision you need to make when assigning the diagnosis code(s) for this case is whether the tonsillitis is chronic or acute. The choice leads to the following distinct code families:

• J03.- (Acute tonsillitis)
• J35.0- (Chronic tonsillitis and adenoiditis)

Hint: ICD-10-CM does not define a specific time period to distinguish between chronic or acute tonsillitis. However, generally accepted clinical guidelines indicate that patients with acute tonsillitis will have symptoms present for up to two weeks.

“Chronic tonsillitis means that the patient is still experiencing symptoms of the same episode of tonsillitis after two weeks,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Caution: However, the physician’s final diagnosis is the final word on the complexity of the tonsillitis, according to Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “If the note does not indicate acute or chronic, the coder/biller should query the provider for more specific diagnosis. The coder/biller cannot make that determination and usually will default to acute with lack of further documentation,” Holle explains.