Otolaryngology Coding Alert

Question: What is the appropriate way to bill a tonsillectomy done with a UPPP? Should we bill the tonsillectomy as the primary procedure and then bill the UPPP with modifier -59, or is it the other way around?

Texas Subscriber

Answer: The procedure with the greatest number of relative value units (RVUs) should be billed first, says Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wash. In this case, the uvulopalatopharyngoplasty (UPPP) should be billed first because 42145 (palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) has been assigned 16.49 RVUs. The tonsillectomy has been assigned only 7.33 RVUs (42826, tonsillectomy, primary or secondary; age 12 or over) and should therefore be billed second, with modifier -59 (distinct procedural service) appended.

Many otolaryngologists have reported denials when billing UPPP and tonsillectomy during the same session, Thompson says. Some carriers believe the tonsillectomy is incidental to the UPPP, despite statements to the contrary by professional associations such as the American Academy of Otolaryngologists Head and Neck Surgeons and the AMA.

Therefore, Thompson says, documentation should indicate medical necessity for the tonsillectomy (preferably by using a diagnosis other than obstructive sleep apnea, which provides medical necessity for the UPPP).