Otolaryngology Coding Alert

Question: The March 2004 Otolaryngology Coding Alert states that the National Correct Coding Initiative (NCCI) bundles tonsillectomy (42826) with uvulopalatopharyngoplasty (UPPP) (42145). I thought that the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) successfully lobbied to have these procedures unbundled in 2002.

New York Subscriber

Answer: The AAO-HNS did fight the bundle for  tonsillectomy (42826, Tonsillectomy, primary or secondary; age 12 or over) and UPPP (42145, Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvolopharyngoplasty]). But, they failed to get insurance companies to overturn the edit.

Originally, private insurers included the tonsillectomy with the UPPP. The AAO-HNS and otolaryngology coders appealed these bundles, based on the fact that Medicare did not bundle the codes.

But then Medicare bundled 42826 with 42145. NCCI 8.0 in 2002 created this edit, which meant coders had no reason to appeal 42826 denials. A summary of AAO-HNS' discussion with CMS regarding the edit's implementation is available at www.entlink.net/practice/pm_news/article.cfm. You may also view the Academy's policy statement, which supports the tonsillectomy as a separate procedure, at www.entlink.net/practice/rules/tonsillectomy_uppp.cfm.

You may sometimes use a modifier on the UPPP code to increase payment. If a case is particularly complicated and takes a long time, you may append modifier -22 (Unusual procedural services) to 42145 to indicate an unusual procedural service. But cases that warrant using the modifier are the exception, not the rule, for every tonsillectomy with UPPP.