Otolaryngology Coding Alert

 When the patient is age 12 or older, you should assign:
  

Warning: Prompt T&A payment depends on your selecting the right age-specific code. If you use 42820 on a 13-year-old child" the insurance company will deny the claim " says Eileen Antico CPC an otolaryngology coding specialist at Nemours Clinical Management Program (12 otolaryngologists) in Orlando Fla. "Most payers' computer systems have claim edits in place that would drop a mismatched age and code claim from processing."
 
Step 2: Look for Primary Secondary Adenoidectomy

If the otolaryngologist performs an adenoidectomy alone you must also check the operative report to see whether the patient had a secondary adenoidectomy.
 
You should use 42830 or 42831 for a primary adenoidectomy. But if the patient has had adenoids previously removed you should code a secondary adenoidectomy with 42835 or 42836. "A secondary adenoidectomy removes the regrowth of the adenoids or any portion missed during the first procedure " Antico says.
 
Coding example: An otolaryngologist removes portions of the adenoids that regrew after a 6-year-old patient's primary adenoidectomy. Because the surgeon performs a secondary procedure - and CPT distinguishes between primary and secondary adenoidectomies - you should report this operation with 42835.
 
Watch out: Even though an otolaryngologist may perform a primary or secondary tonsillectomy CPT lumps both procedures into one code. Although the patient's medical record should reflect whether the patient previously had tonsils removed you still use the same code.
 
Step 3: For T&A Report 42820 or 42821

When coding for a combination T&A you also don't have to distinguish whether the otolaryngologist performed a primary or secondary adenoidectomy.
 
"Nowhere is [42820-42821] confined to primary or secondary patient types " says Andrew Borden CCS-P CPC CMA reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee.

Use 1 Code to Describe Tonsillectomy and Primary or Secondary Adenoidectomy

If the otolaryngologist performs both tonsillectomy and adenoidectomy for the first or second time you should report only 42820 or 42821. Insurers consider separately reporting the procedures with 42825/42835 unbundling "which is the biggest no-no " Borden says.
 
Insurers will correct unbundling errors: The insurance companies are bundling 42825 and 42835 together and recoding as 42820 says Mary Hameister reimbursement manager at Pediatric Ear Nose & Throat of Atlanta. The insurers explain that you should use 42820 when a surgeon performs a T&A regardless of whether the patient previously had adenoids removed.
 
Coding example: An otolaryngologist performs a T&A on a 10-year-old patient who previously had his adenoids removed. In this case you should submit the tonsillectomy and secondary adenoidectomy with 42820. "Under strict coding guidelines the closest code is always going to be 42820 " Borden says. "The code most closely approximates the procedure(s) performed but also neatly combines the two surgeries."