Otolaryngology Coding Alert

Although it is frequently performed and relatively straightforward, tonsillectomy may create billing problems, particularly for the inexperienced otolaryngology coder.
 
Coders face unique challenges when distinguishing tonsillectomy from adenoidectomy (removal of the adenoids), uvulopalatopharyngoplasty (UPPP) and somnoplasty, any of which may be combined with tonsillectomy in the operating room.
 
The patient's postoperative condition (especially when there is postoperative bleeding), as well as a carrier's preauthorization requirements, also affects the coding process.
 
Tonsillectomy, removal of the palatine tonsils due to bacterial infection or hypertrophia, is reported as 42825 (tonsillectomy, primary or secondary; under age 12) or 42826 ( age 12 or over). 

Although adenoidectomy is often performed as a combined procedure with tonsillectomy and reported as 42820 (tonsillectomy and adenoidectomy; under age 12) or 42821 ( age 12 or over), the procedure is increasingly performed apart from tonsillectomy. Adenoidectomy helps children who have middle-ear diseases or infections, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's Editorial Panel and Executive Committee.
 
CPT 2002 identifies adenoidectomy as being either primary"" or ""secondary"":
 
"

42830 adenoidectomy primary; under age 12

42831 age 12 or over

42835 adenoidectomy secondary; under age 12

42836 age 12 or over.
 
 
Note: Coding Illustrated: Head and Neck defines "primary" as "the initial removal of the adenoid " whereas "secondary" is "to remove portions of the adenoid missed during the primary procedure."
 
Adenoidectomy may include myringotomy with tubes reported as 69433  (tympanostomy [requiring insertion of ventilating tube] local or topical anesthesia) or 69436 ( general anesthesia). It is important to make sure the correct diagnosis code is linked to the appropriate procedure Eisenberg says noting that the adenoidectomy is not performed in these cases because of adenoidal hypertrophy.
 
"You can't put down hypertrophy of the adenoids for the adenoidectomy because in this case it isn't accurate and you can't put down chronic mucoid otitis media (381.2x) or secretory otitis media (381.3) because these codes do not support an adenoidectomy and will be bumped out of the carrier's system and be denied " he says.
 
The appropriate otitis media code in these cases should be linked to the appropriate tympanostomy code while a diagnosis of chronic adenoiditis (474.01) should be associated with the adenoidectomy Eisenberg says.
 
Note: When adenoidectomy and tympanostomy are performed during the same session the procedures are reported from highest to lowest RVU value.
 
For example if the otolaryngologist performed a primary adenoidectomy and a tympanostomy under general anesthesia on a 7-year-old child 42830 would be reported first because it has been assigned more RVUs (5.26) than 69436 (4.15).
 
The carrier will apply multiple-procedure rules and reduce reimbursement for the tympanostomy 50 percent.

UPPP is used 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.
 
Although the Correct Coding Initiative (CCI) does not bundle tonsillectomy with 42145 many third-party payers will not pay for tonsillectomy performed at the same time as a UPPP. Carriers maintain that the tonsillectomy is incidental a claim that the American Medical Association and the American Academy of Otolaryngologists-Head and Neck Surgery reject.

Somnoplasty a procedure similar to electrocautery or laser surgery in that it destroys tissue without excision is often used to clear an airway of a hypertrophied tonsil rather than treat infection.
 
There is no specific code for tonsillectomy performed using somnoplasty because CPT does not assign procedure codes based on the types of instruments used. Coders therefore assign 42825 or 42826 to tonsillectomy using somnoplasty.
 
Otolaryngologists who perform somnoplasty procedures may encounter coverage problems with carriers although there are likely to be fewer denials with tonsillectomy using somnoplasty than for the other procedures that use this technique.

Postoperative Bleeding

Postoperative bleeding occurs in up to 3 percent of all tonsillectomy patients usually within the first 10 days after surgery. Patients may be treated in the physician's office may require hospitalization or may even need to return to the operating room. Post-tonsillar hemorrhage codes include:

42960 control oropharyngeal hemorrhage primary or secondary (e.g. post-tonsillectomy); simple

42961 ... complicated requiring hospitalization

42962 ... with secondary surgical intervention.

Note: CPT 2002 also lists parallel codes for postadenoidectomy (nasopharyngeal) hemorrhages (42970-42972).
 
Payment using these codes may be difficult to obtain from carriers especially if the postoperative bleeding is treated during the 90-day global period of the original tonsillectomy.
 
Commercial payers are more likely to pay for post-tonsillar hemorrhage control than Part B carriers because Medicare considers a postoperative bleed a complication and will not pay separately for treating it unless it requires a return to the operating room says Barbara Cobuzzi MBA CPC CPC-H an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood N.J.
 
Modifier -78 (return to the operating room for a related procedure during the postoperative period) should be appended to 42962 or 42972 in these cases. "Unless they follow Medicare policy on this matter and many do private payers are more likely to pay separately for hemorrhage control that did not require a return to the operating room " Cobuzzi says. She notes however that the carriers may differ among themselves on how the procedures should be reported. For example some carriers may require the appropriate hemorrhage-control code and nothing else but others may require modifier -58 (staged or related procedure or service by the same physician during the postoperative period) or another modifier.
 
Note: CPT 2002 and the Medicare Carriers Manual differ on what is included in the global surgical package. CPT states that the global package only includes care without complications; Medicare inter-prets the package to include complications unless a return to the operating room is required which is why the repair of a post-tonsillar bleed on a Medicare patient is paid separately only if the patient had to return to the operating room.

Strep and other bacterial infections are treated with antibiotics: Tonsillectomy or adenoidectomy is recommended either because the patient suffers recurrent infection despite antibiotic therapy or because the patient has difficulty breathing due to enlarged tonsils or adenoids.
 
Medical reasons for the surgery must be noted in the patient's chart because the carrier may require documentation that indicates medical necessity before preauthorization. For example the documentation could indicate that the patient continues to suffer from chronic tonsillitis even after being treated several times with various antibiotics.
 
Carriers may also limit coverage for tonsillectomies and/or adenoidectomies due to pre-existing conditions or limit the number of times these procedures may be performed. Carriers accept diagnoses related to chronic tonsillitis and/or adenoiditis such as 474.1x (hypertrophy of tonsils and adenoids) 474.9x (unspecified chronic disease of tonsils and adenoids) and 475 (peritonsillar abscess) depending on the procedure. Individual carriers also may accept sleep apnea (780.5x) snoring (786.09) otitis media (381.xx) and several related benign and malignant neoplasm codes.

Other Billing Issues

One Side or Two? Medicare and most other carriers consider tonsillectomy a bilateral procedure which means the value of the procedure has been calculated based on the assumption that both sides of the throat are being treated. Modifier -52 (reduced services) should be appended to the appropriate tonsillectomy code if only one tonsil is excised or destroyed.

Lingual Tonsil Removal. Lingual tonsils can be a source of recurrent or chronic infection and may be removed (42870 excision or destruction lingual tonsil any method [separate procedure]). Removal of lingual tonsils is a more complex procedure than palatine tonsil excision and is paid separately only when performed as the sole procedure during an operative session. If the lingual tonsils are removed as part of a tonsillectomy or adenoidectomy or as part of a related pharyngeal procedure it is considered incidental to the primary procedure and would not be paid separately.

Radical Resection of Tonsils. These procedures are much more extensive than a tonsillectomy and as a result reimburse at a much higher rate:

42842 radical resection of tonsil tonsillar pillars and/or retromolar trigone; without closure

42844 closure with local flap (e.g. tongue buccal)

42845 closure with other flap.

All three codes describe radical procedures involving the removal of large amounts of tissue. The surgical opening in 42842 is so large that it is packed open with a graft being placed at a subsequent session. Codes 42844 and 42845 require closure with flaps: 42844 uses a local flap while 42845 uses a flap that may be rotated from the chest and may include some reconstruction and grafting.