Otolaryngology Coding Alert

Question: We’ve received a denial for a surgery on a patient younger than 12 involving a tonsillectomy and secondary adenoidectomy. The patient had a previous adenoidectomy two years prior. The denial states that code 42820 may only be submitted for reimbursement once in a patient’s lifetime. How should we resubmit this claim in order to receive reimbursement?

Utah Subscriber

Answer: There are rare instances in which adenoids can regrow in young patients following an adenoidectomy. If you’ve got documentation to support that this is one of those clinical scenarios, you should include it in an appeal to the payer. If the surgeon is instead removing residual scar tissue from the previous adenoidectomy, then you do not have sufficient documentation to justify reporting code 42820 (Tonsillectomy and adenoidectomy; younger than age 12) or 42835 (Adenoidectomy, secondary; younger than age 12). You should only report code 42835 for a secondary (regrowth) of the adenoids without an included tonsillectomy.

Keep in mind that, given the patient is a child, the payer may not follow National Correct Coding Initiative (NCCI) protocol. So, it may be worth a call to the payer to find out if their bundling edits do, in fact, bundle 42835 and 42825. If you find the payer does not bundle 42835 and 42825 — or the payer does not allow the unbundling of these two codes under special circumstances — this non-payment may be remedied through a claim resubmittal.

If the documentation only supports the surgical removal of residual adenoidal scar tissue, then you should not include this portion of the surgery in your coding considerations. Instead, you will only report code 42825 (Tonsillectomy, primary or secondary; younger than age 12). If the documentation supports the secondary removal of the adenoids in addition to the tonsillectomy, you should appeal the denial for 42820. Given the NCCI Procedure-to-Procedure (PTP) edit between 42825 and 42835 revealing a modifier indicator of “0,” you should not resubmit using these respective codes.