Otolaryngology Coding Alert

Know the age cutoff for these surgical codes.

When your otolaryngologist performs a tonsillectomy/adenoidectomy, you have to answer several questions before choosing the correct code.

Such as …: Knowing exactly what the provider removed, and the patient’s age, are your top priorities when scouring the claim for relevant coding info. You’ll also need to know the difference between primary, secondary, and total tonsillectomy/adenoidectomy to submit a spot-on claim.

Get everything you need to know with this expert advice on coding tonsillectomies and adenoidectomies. We’ll show you how to code for patients of all ages, and how to use the tonsillectomy/adenoidectomy codes that you’ll see most often in your otolaryngology practice.

Step 1: Know Tonsillectomy/ Adenoidectomy Codes

In an otolaryngology practice, you’ll likely choose your tonsillectomy/adenoidectomy code from an eight-code set: two tonsillectomy codes, four adenoidectomy codes, and two combination codes (for adenotonsillectomy), explains Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of Healthcare Resource Management Inc. in Spring Lake, N.J:

Tonsillectomy: Report 42825 (Tonsillectomy, primary or secondary; over age 12) or 42826 (… age 12 or over) for this procedure, depending on patient age.

Adenoidectomy: Report one of the following codes, depending on patient age and whether the procedure is primary or secondary:

• 42830, Adenoidectomy, primary; under age 12
• 42835, Adenoidectomy, secondary; under age 12
• 42831, Adenoidectomy, primary; age 12 or over
• 42836, Adenoidectomy, secondary; age 12 or over.

Adenotonsillectomy: This term defines removal of both the adenoids and tonsils, Brink confirms. Choose 42820 (Tonsillectomy and adenoidectomy; under age 12) or 42821 (… age 12 or over) for adenotonsillectomy, depending on patient age.

Step 2: I.D. Tonsillectomy, Adenoidectomy … or Both

For coding purposes a tonsillectomy is the removal of the tonsils and an adenoidectomy is the removal of the adenoids, according to Lisa Jones, CPC, coder at South Florida ENT Associates in Hollywood. This is a simple but vital distinction that you’ll need to remember when the provider only removes the patient’s tonsils or adenoids — and that fact isn’t spelled out in the encounter notes.

Quick anatomy lesson: In case there’s any confusion about what the provider removed, keep this in mind: “Your tonsils are in the back of your throat. Your adenoids are higher up, behind your nose,” explains Donina King, CPC-A, medical coder on Long Island in New York City. If encounter notes indicate surgical anatomy but don’t spell out whether it was a tonsillectomy or an adenoidectomy — or both — look at where the otolaryngologist performed the removal for coding clues.

Remember: Primary, Secondary Matters … Sometimes

A quick review of the aforementioned tonsillectomy/adenoidectomy code set shows that there are some subtle differences between the codes. Here’s a rundown of what to keep in mind so you don’t trip up on your adenoidectomy/tonsillectomy claims:

• There aren’t separate tonsillectomy codes for primary and secondary procedure types. So, whether the physician is performing a primary or secondary tonsillectomy, you’ll still choose between 42825 and 42826, depending on patient age.
• There are separate codes for primary adenoidectomy and secondary adenoidectomy. So, you’ll choose 42830 or 42831, depending on patient age, for primary adenectomies; if the otolaryngologist needs to go back and remove more adenoidal tissue, use 42835 or 42836.
• There is no mention of primary or secondary in the adenotonsillectomy codes 42820 and 42821. If encounter notes verify that the otolaryn­gologist removed the patient’s tonsils and adenoids, check the patient’s age and you’re ready to make a code choice.