Otolaryngology Coding Alert

Question: Why do insurance companies bundle UPPP (42145) with a tonsillectomy (42825) when I report them on the same claim? These are two separate procedures that can be done with or without each other. Is there a better way to code them?

Georgia Subscriber

Answer: The short answer is, payers may consider tonsillectomy incidental to uvulopalatopharyngoplasty (UPPP) and so won't pay the tonsillectomy separately.

ENTs use UPPP to treat patients who snore, suffer from sleep apnea, or present with malignant lesions of the hard or soft palate or uvula. When performing UPPP (42145, Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]), the otolaryngologist may remove hypertrophied or inflamed tonsils and leave healthy tonsils intact.

  Difference of opinion: Although the Correct Coding Initiative (CCI) does not bundle tonsillectomy (42825, Tonsillectomy, primary or secondary; younger than age 12) with 42145, many third-party payers will not pay for tonsillectomy performed at the same time as a UPPP. Carriers say the tonsillectomy is incidental, a claim that the AMA and the American Academy of Otolaryngologists-Head and Neck Surgery reject.

If you appeal the denial of a tonsillectomy on a child under the age of 12, point out the increased risk of complications and post-tonsillar bleeds found in children. This is probably why 42826 is not bundled with 42145 and merits separate payment.

Take note: For older patients (42826, Tonsillectomy, primary or secondary; age 12 or over), CCI bundles the procedures.

Document the diagnosis: Some insurers accept that the two procedures are separate and will pay for both. Make sure that the surgeon's documentation reflects whether he performed the tonsillectomy for a different reason than the UPPP. ENTs usually perform the UPPP for sleep apnea (such as 780.57, Unspecified sleep apnea), and you can separately report the tonsillectomy if the surgeon performs it due to hypertrophy of tonsils (474.11, Hypertrophy of tonsils and adenoids; tonsils alone).

Many non-Medicare insurers follow CPT rules, not CCI guidelines. The bottom line is that you will have to confirm whether your insurer allows you to report both procedures together.

Bonus tip: If the tonsillectomy caused the surgical procedures to be substantially increased in complexity and risk and the operative note documents this, you may submit the UPPP with a 22 modifier (Increased procedural services) to account for the tonsillectomy with the UPPP.