Otolaryngology Coding Alert

Question: Why is procedure 42826-51 (tonsillectomy, primary or secondary; age 12 or over) considered part of 42145 (palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]; multiple procedures) by most carriers? According to NCCI edits, it is not bundled.

Carrie Cardin, CPC
St Lucie Martin Otolaryngology, FL

Answer: The National Correct Coding Initiative (NCCI) does not contain a complete list of coding edits. In fact, any edit that is considered a standard bundling rule, either by the Resource Based Relative Value System (RBRVS) or CPT, would not be included in the NCCI edits.

According to the way the RBRVS defines surgical procedures, incidental services cannot be billed separately, a standard thats written in the definition of surgeries under RBRVS. Even though RBRVS guidelines originate with Medicare, most private carriers have adopted at least some of these payment theories and mechanisms.

Though these come from the Health Care Financing Administration (HCFA), most insurance firms have adopted some payment mechanisms and theories.

For palatopharyngoplasty (UVPP), there is no medical necessity for the tonsil removal other than to allow better access for the palatopharyngoplasty. In other words, the tonsillectomy is considered incidental and does not warrant separate reimbursement, says Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Phoenix, AZ.

However, if the patient had a history of acute or chronic tonsillitis (474.00, chronic tonsillitis, 474.02, chronic tonsillitis and adenoiditis) or 474.10-474.12 (hypertrophy of tonsils and/or adenoids), medical necessity for the tonsillectomy would be shown, assuming the UVPP was done for a separate diagnosis, and therefore it would be appropriate to bill for both using a -59 modifier (distinct procedural service) on the tonsillectomy, because it was not being performed simply to access the UVPP.