Otolaryngology Coding Alert

ENT coders who report tonsillectomies as one of their practice's mainstays must properly distinguish the operation from adenoidectomies and know when to code combined procedures to avoid fraud.

Although otolaryngologists often perform adenoidectomies with tonsillectomies, physicians may do a tonsillectomy without an adenoidectomy or vice versa based on the patient's history or diagnoses, says Rhonda Buckholtz, CPC, office manager for Crawford and FitchEar, Nose and Throat in Franklin, Pa.

CPT contains codes that describe each of these operations alone, as well as jointly, all of which are age-based. Many coders fail to remember to code based on this straightforward time line. "The most common mistake made when billing these procedures is billing at the wrong age level, causing the claim to be denied and then having to be resubmitted," Buckholtz says. Therefore, let's review how to code the procedures correctly.

The first step in reporting a tonsillectomy alone is knowing the patient's age. CPT designates two age-specific tonsillectomy codes. When a physician removes diseased tonsils in a patient who is under 12 years of age, you should bill 42825 (Tonsillectomy, primary or secondary; under age 12), Buckholtz says. For patients 12 and older, report 42826 ( age 12 or over).

The adenoidectomy codes require the same age split. But they add one more concept: primary versus secondary, says Darlene Reed, CPC, certified coder for Northland Ear, Nose and Throat in Liberty, Mo. When the physician initially removes the adenoids, CPT considers the adenoidectomy a primary procedure. After the initial removal, the otolaryngologist sometimes removes portions of the adenoid tissue that may have regrownafter the primary procedure. In this case, he performs a secondary procedure, Reed says.

CPT breaks both primary and secondary adenoidectomy into age-specific codes. For a primary operation in which the patient is younger than age 12, report 42830 (Adenoidectomy, primary; under age 12), Reed says. When the patient is age 12 or older, you should assign 42831 ( age 12 or over). The two secondary codes include 42835 (Adenoidectomy, secondary; under age 12)for patients younger than 12 years and 42836 ( age 12 or over) for patients 12 years and older.

The age trend keeps rolling when reporting combined tonsillectomy and adenoidectomy. Instead of submitting the individual codes, however, you should switch to 42820 (Tonsillectomy and adenoidectomy; under age 12) and 42821 (... age 12 or over). When the physician performs both a tonsillectomy and an adenoidectomy at the same session, you should bill 42820 for those patients under the age of 12 or 42821 for those patients age 12 and over, Buckholtz says.

Do not make the mistake of unbundling the procedures and reporting the individual codes. "Because CPT assigns a code for T&A's, it would be inappropriate to bill the codes designated specifically for a tonsillectomy or an adenoidectomy," Buckholtz stresses.

When billing one or both of these procedures, linking the codes to the appropriate diagnoses is crucial for payment. Make sure the diagnosis reflects the procedure performed. For instance, surgeons often remove the palatine tonsils due to repeat bacterial infection or hypertrophy. To support the claim, use a diagnosis that reflects tonsillitis, such as 463 (Acute tonsillitis) or 474.11 (Hypertrophy of tonsils alone), Buckholtz says.

Examples of acceptable diagnoses that support adenoidectomy include 381.1x (Chronic serous otitis media), 381.2x (Chronic mucoid otitis media), 381.81 (Dysfunction of Eustachian tube), 474.01 (Chronic adenoiditis) and 474.12 (Hypertrophy of adenoids alone). Some common ICD-9 codes for T&A are 474.00 (Chronic tonsillitis), 474.02 (Chronic tonsillitis and adenoiditis) and 474.10 (Hypertrophy of tonsils with adenoids).

Another important way to ensure coverage of these procedures is to obtain preauthorization from the payer. Insurers may require you to submit documentation showing repeated strep or other infections before they will grant prior authorization for tonsillectomy and adenoidectomy. This is because surgery should be the last course of treatment for an individual who has repeat infections.

Standard medical practice requires doctors first to treat strep and other bacterial infections with antibiotics. When a patient has recurrent infections that are unresponsive to antibiotics or has difficulty breathing due to enlarged tonsils or adenoids, a physician may then recommend surgery as an alternative. The otolaryngologist must document such medical reasons for the surgery in the patient's chart.

If you obtain prior authorization, include the prior-authorization number on the claim submission and on any correspondence relating to the claim.

Be aware that many insurers place additional restrictions on 42820-42836. Most companies will not cover preexisting conditions until the patient meets the plan's pre-existing-condition period. These clauses may not cover major surgeries for prior conditions within the first 180 days of the patient's coverage. In addition, payers may limit the number of times the patient may have the operations.