Otolaryngology Coding Alert

Question: The ENT saw a 24-year-old patient in the ER for a peritonsillar abscess. Then, she admitted the patient for an I&D of abscess and also a tonsillectomy. Can we bill for both procedures or just the removal?

Answer: The two procedures you describe (42700, Incision and drainage abscess; peritonsillar, and 42826, Tonsillectomy, primary or secondary; age 12 or over) are not bundled together per the National Correct Coding Initiative edits.

However: The payer should not have to reimburse for an incision and drainage (I&D) for a part that the otolaryngologist removed for the tonsillectomy. To report both the incision and drainage (I&D) and the tonsillectomy, the ENT must have performed the I&D in a different site from the parts of the tonsils that she removed. Be sure that the different sites are documented in the op report.

The only other reason to charge for both when performed in the same area is if the ENT attempted the I&D as conservative care, in hopes of avoiding the tonsillectomy, and then she found that the I&D was not sufficient and had to return to do the tonsillectomy. If this is the case, the ENT should clearly explain the medical decision making in the op note.

-- Answers to You Be the Coder and Reader Questions reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of New Jersey-based CRN Healthcare Solutions.