Otolaryngology Coding Alert

Otolaryngologists who review Correct Coding Initiative version 8.0 (CCI 8.0) may be disappointed to find that the CCI now bundles tonsillectomy 42826 (tonsillectomy, primary or secondary; age 12 or over) with uvulopalatopharyngoplasty (UPPP) 42145 (palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) and gives the edit a "0" indicator (i.e., physicians cannot append a modifier to 42826 to bypass the edit).
 
Note: Otolaryngologists may also be dismayed to find that UPPP pays slightly less in 2002 (16.02 RVUs) than in 2001 (16.49 RVUs). The cut in the 2002 Medicare fee schedule conversion factor, coupled with the reduced RVU rate, means that otolaryngologists will receive much less for UPPP than they received in the past.

The Bundling Debate

Otolaryngologists have long insisted that tonsillectomy and UPPP not be bundled since tonsillectomy is not always performed during UPPP, says Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wash. Although the otolaryngologist would probably remove inflamed or hypertrophied tonsils during UPPP, she says that the otolaryngologist may decide to leave healthy or small tonsils in place. "Otolaryngologists do not routinely remove tonsils when performing UPPP these days," Thompson says. 
 
Medicare appears to be using the new edit to say that tonsillectomy with UPPP should be standard medical practice, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "The people in charge of the CCI apparently have come to believe that tonsillectomy is performed with UPPP often enough to make it incidental," Callaway says.
 
Although most Medicare carriers have been paying separately for tonsillectomy and UPPP performed during the same session, many commercial carriers had stopped paying separately for tonsillectomy long ago on the grounds that tonsillectomy is incidental to UPPP. Bundling tonsillectomy with UPPP, therefore, means not only that Medicare will no longer pay separately for tonsillectomy and UPPP performed during the same session but also that private payers will be able to use the edit to justify their denials.

Reimbursement Strategies

Unusual Circumstances. It is possible to obtain reimbursement for a tonsillectomy performed at the same time as a UPPP, but only in unusual circumstances, Callaway says.
 
A morbidly obese patient with unusually small tonsils and a small mouth, for example, may require the otolaryngologist to reposition the tongue blade from one area to the next so as to see the tonsils in their entirety. In this case, it may be appropriate to append modifier -22 (unusual procedural services) to 42145 to indicate that the procedure took much more time and effort than normal. "The otolaryngologist must document that the removal of the tonsils was significantly more complicated than usual. If the op note only says, 'Tonsils were removed,' you probably won't get any extra reimbursement," Callaway says.
 
Note: It can be extremely difficult to obtain additional reimbursement using modifier -22. Make sure that any claim for modifier -22 includes documentation that is detailed enough to support the claim, preferably a short letter that indicates the reason for and amount of additional work.
 
Alternative Procedures. While she agrees that the 42145/42826 edit is inappropriate, Tara Kaye, appeals coordinator with Atlanta ENT, a large otolaryngology practice with offices throughout the Atlanta area, sees little point in battling with carriers. "Otolaryngologists must decide how they will deal with the situation now," she stresses. One solution, Kaye suggests, would be to use alternative procedures to achieve the same results. For example, somnoplasty (radiofrequency reduction) of the soft palate or uvula can often be performed in place of UPPP. The tonsillectomy would be performed on another date, billed to the carrier, and paid (since it would be the only service provided in that operative session). If somnoplasty is an option, the otolaryngologist should collect payment and a signed waiver from the patient before the procedure is performed because many carriers do not cover it.