Otolaryngology Coding Alert

Question: Two weeks after surgery, a patient presents for a tonsillectomy follow-up visit. The otolaryngologist documents that the surgery alleviated the child's chronic tonsillitis and that the patient has made a normal recovery. Should I code the office visit?

North Carolina Subscriber

Answer: Tonsillectomy codes (42825, Tonsillectomy, primary or secondary; under age 12; and 42826, ... age 12 and over) contain 90 global days. Therefore, the surgical package includes the follow-up visit. Although you shouldn't charge for this visit, you should report it with 99024 (Postoperative follow-up visit, included in global service).

You should, however, charge for any visits that are not related to the surgery. For instance, the child presents with an ear infection (382.9, Unspecified otitis media) during 42825's global period. In this case, you should report the office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to indicate that the E/M service is unrelated to the surgery.