Otolaryngology Coding Alert

Tip: Documentation of ‘enlargement of adenoids’ signals same condition.

The adenoids are tonsil-like glands located at the back of the nose. When a patient is diagnosed with hypertrophy of adenoids, it means he has enlarged adenoid tissues that can potentially block nasal passages completely or cause sleep disturbances. 

Code choice: If the otolaryngologist documents hypertrophy of adenoids, you should report diagnosis 474.12 (Hypertrophy of adenoids alone). 

ICD-10 change: You’ll shift to J code J35.2 (Hypertrophy of adenoids) when reporting hypertrophy of adenoids when the system changes to ICD-10-CM on October 1, 2015. Another term that a physician might use to describe this condition is “enlargement of adenoids.” 

Coder tips: Your physician may perform nasal endoscopy to examine a patient’s upper airways for hypertrophy of adenoids, especially if the patient’s condition is not improving or the otolaryngologist cannot get an accurate diagnosis from a manual nasal exam with a speculum. You would report this with 92511 (Nasopharyngoscopy with endoscope [separate procedure]).

To treat the condition, a physician would most likely perform adenoidectomy, which you would report with 42830 (Adenoidectomy, primary; younger than age 12) or 42831 (…age 12 or over) for primary procedures, and 42835 (Adenoidectomy, secondary; younger than age 12) or 42836 (…age 12 or over) for secondary procedures. 

Secondary adenoidectomies are for the removal of tissue that was left behind after the first adenoidectomy or to remove adenoid tissue that has grown back. Be aware that insurers might require you to submit documentation showing repeated strep or other infections before they will grant prior authorization for adenoidectomy. Their reasoning is that surgery should be the last course of treatment for an individual who has repeat infections. 

Best practice: Before scheduling the surgery, get preauthorization from the payer to ensure coverage.