Otolaryngology Coding Alert

Tip: Use this diagnosis when ENT documents "enlargement of adenoids."

Patients with hypertrophy of adenoids have enlarged adenoid tissues that can potentially block nasal passages completely, or can cause sleep disturbances. Adenoids are tonsil-like glands located at the back of the nose.

Currently, an otolaryngologist who sees a patient with hypertrophy of adenoids should code 474.12 (Hypertrophy of adenoids alone) to report the condition when using the ICD-9-CM manual.

When ICD-10 goes into effect, you will have to shift to J code J35.2 (Hypertrophy of adenoids) when reporting hypertrophy of adenoids. Another term that a physician would use to describe this condition is "enlargement of adenoids."

Documentation: Insurers may require you to submit documentation showing repeated strep or other infections before they will grant prior authorization for adenoidectomy because surgery should be the last course of treatment for an individual who has repeat infections. In this case, it would be best for you to obtain preauthorization from the payer to ensure coverage.

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 nasal septum exam. 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, where there had been a prior adenoidectomy and there has been regrowth of adenoid tissue which needs to be removed. The adenoids are often removed as part of a bundled procedure with a tonsillectomy, 42820 (Tonsillectomy and adenoidectomy; younger than age 12) or 42821 (age 12 or over).