Otolaryngology Coding Alert

Remember to check NCCI edits to avoid bundling pitfalls.

Chances are, your otolaryngologist performs their fair share of tonsillectomies and adenoidectomies. When billing these surgeries, you must consider multiple factors — age, combination codes, bundling restrictions, possible post-op bleeding, etc. — in order to arrive at the correct code for the procedures performed.

Here are some handy hints to help you avoid common mistakes and secure proper payment for your ENT’s work the next time you have to tackle one of these claims.

Hint 1: Start by Confirming the Patient’s Age

The first distinction between tonsillectomy and adenoidectomy codes is based on two age groups: under 12 years, or age 12 and over. Your choices are as follows:

• 42820 (Tonsillectomy and adenoidectomy; younger than age 12)
• 42821 (… age 12 or over)
• 42825 (Tonsillectomy, primary or secondary; younger than age 12)
• 42826 (… age 12 or over)
• 42830 (Adenoidectomy, primary; younger than age 12)
• 42831 (… age 12 or over)
• 42835 (Adenoidectomy, secondary; younger than age 12)
• 42836 (… age 12 or over)

Watch NCCI edits: Medicare’s National Correct Coding Initiative (NCCI) edits reinforce the importance of paying attention to the patient’s age. The bundled codes for tonsillectomies and adenoidectomies include each of the age pairs (either under age 12, or age 12 and over).

“To me, you cannot ever code these together because either the patient is 12 years old or over, or the patient is younger than 12,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey. “They can’t be both, so the descriptors will never coexist.”

Hint 2: Know Definitions, Implications of ‘Primary’ vs. ‘Secondary’

Sometimes the surgeon doesn’t remove the entire tonsil or adenoid during the initial procedure, or the tissue grows back following a tonsillectomy or adenoidectomy. That’s the source of the terms “primary” and “secondary” in the codes. “Primary” refers to the initial surgical removal of the tonsil or adenoid. “Secondary” refers to a subsequent surgery to remove portions of the tonsil or adenoid missed during the initial procedure or that grew back after the primary procedure.

Don’t lose out on $19: Since CPT^® provides different codes for primary and secondary adenoid removal, you must determine from the surgeon’s documentation whether they performed a primary or secondary adenoidectomy. Billing a secondary adenoidectomy when the surgeon performed a primary could cost you reimbursement — $19.31 to be exact (42830 pays $216.88 and 42835 pays $236.19, based on the 2023 national unadjusted conversion factor of 33.8872).

Hint 3: Pay Close Attention to Combination Codes

The combination tonsillectomy/adenoidectomy (T&A) codes (42820-42821) present an additional coding pitfall you’ll need to avoid: If the surgeon performs both procedures during the same surgical encounter, you must submit the combined T&A code.

“If you were to report 42826 [for tonsillectomy] and 42836 [for secondary adenoidectomy] separately, for instance, you would be committing an unbundling,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Washington.

Also, don’t ever report a stand-alone tonsillectomy or adenoidectomy code in addition to one of the combination codes (42820-42821). NCCI creates bundles for all those code pairs, with no option to override the edits.

Potential snag: But what if the surgical note specifies that the adenoidectomy is secondary — shouldn’t you use the more specific adenoid code and separately report a tonsillectomy code?

No. The T&A combination codes don’t distinguish between primary and secondary adenoidectomy. Regardless of documentation about a secondary excision, “if the surgeon performs a tonsillectomy and adenoidectomy at the same session, you must use the appropriate combination code, 42820 or 42821, based on the patient’s age,” Bucknam says.

NCCI affirms this bundling rule by creating edit pairs for each separate tonsillectomy code (42825-42826) with each separate adenoidectomy code (42830-42836). These edit pairs have a modifier indicator of “0,” which means you cannot override the bundles with any modifier.

Hint 4: Avoid Appending the “Bilateral” Modifier

When your surgeon removes tonsils and/or adenoids on both sides, avoid the urge to append modifier 50 (Bilateral procedure). “Modifier 50 does not apply to tonsillectomy and adenoidectomy codes (42820-42836), because the codes assume bilateral surgery,” Bucknam says.

On the other hand, if your ENT performs a unilateral tonsillectomy and/or adenoidectomy, you should report the appropriate code with modifier 52 (Reduced services) appended, per CPT^® Assistant (February 1998).

Hint 5: Consider Separate Charge for Subsequent Hemostasis

When the otolaryngologist controls post-tonsillar or post-adenoidal bleeding during the 90-day global period of the surgery, you may be able to charge separately for the service.

Choose from the following six CPT^® codes to report control of post-tonsillar or post-adenoidal bleeding:

• 42960 (Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple)
• 42961 (... complicated, requiring hospitalization)
• 42962 (... with secondary surgical intervention)
• 42970 (Control of nasopharyngeal hemorrhage, primary or secondary (e.g., postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/ or cautery)
• 42971 (... complicated, requiring hospitalization)
• 42972 (... with secondary surgical intervention)

The AMA designed 42960-42972 knowing they’d be used during the postoperative period, and CPT^® guidelines dictate, “Postoperative complications ... are not included in the surgical package. ... Postoperative complications include conditions such as wound dehiscence, infection and bleeding.”

Translation: For payers that follow CPT^® guidelines, you should report 42960-42972 separately. And if the patient is not brought back to the operating room (OR), append modifier 79 (Unrelated procedure or service by the same physician … during the postoperative period), as the diagnosis, J95.830 (Postprocedural hemorrhage of a respiratory system organ …), would be unrelated to the original surgery, Cobuzzi notes.