Otolaryngology Coding Alert

Question: Can we bill uvulopalatopharyngoplasty (UPPP, 42145) and tonsillectomy (42826) together? We have gotten conflicting advice--one person told us the codes are bundled if the patient is over 12 years, but another coder said we can bill them together regardless of age. Who is right?


Idaho Subscriber

Answer: The National Correct Coding Initiative bundles 42826 (Tonsillectomy, primary or secondary; age 12 or over) into 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). Therefore, if you-re billing a payer that follows the NCCI guidelines (such as Medicare), the insurer will only pay you for the UPPP, not the tonsillectomy.

However, some insurers follow the advice of the August 1997 CPT Assistant, which stated, -From a CPT coding perspective, the tonsillectomy is a separate and distinct procedure,- so you can report 42145 and 42826-51 (Multiple procedures) when you perform these surgeries together. Make sure the surgeon performs the tonsillectomy for a different reason than the UPPP. ENTs usually perform the UPPP for sleep apnea, and you can separately report the tonsillectomy if the surgeon performs it due to hypertrophy of tonsils

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

If the payer is Medicare or one that follows NCCI, and the case was particularly difficult due to the tonsillectomy (for example, over three tonsils, a lot of bleeding, or similar problems), your option is to bill the UPPP appended with modifier 22 (Unusual procedural services), using the documentation to illustrate the unusual and complicated nature of the case.