Otolaryngology Coding Alert

Question: We have a 5-year-old patient who received a tonsillectomy with a revision adenoidectomy. Since the adenoidectomy is a secondary procedure, would we be billing out separate codes for the tonsillectomy and adenoidectomy?

Nebraska Subscriber

Answer: While tonsillectomy code 42825 (Tonsillectomy, primary or secondary; younger than age 12) doesn’t discriminate between primary and secondary, the same is not true for adenectomy codes 42830 (Adenoidectomy, primary; younger than age 12) and 42835 (Adenoidectomy, secondary; younger than age 12).

In the case of a primary tonsillectomy and secondary/revision adenoidectomy, you will apply code 42820 (Tonsillectomy and adenoidectomy; younger than age 12). This is the correct code for all combinations of primary/secondary adenoidectomies and tonsillectomies — including situations where both procedures are secondary.

Fortunately, even for those who make it past this point intent on billing for two separate procedures, a Correct Coding Initiative (CCI) edit will ultimately stall them. According to CCI, you cannot bill 42825 and 42830/42835 together under any circumstances. The only other option, at this point, is to fall back on the combination code 42820. If the patient is age 12 or above, you will want to apply code 42821 (Tonsillectomy and adenoidectomy; age 12 or over).

Remember: The CCI edits for 42825 and 42830/42835 state that 42835 is bundled into 42825. This might confuse some coders into thinking that, in the case of a revision adenoidectomy coupled with a tonsillectomy, they should only be billing out for the tonsillectomy. As you know by now, this is incorrect and you should opt for the combination code 42820.