Otolaryngology Coding Alert

Question: We are confused about the difference between primary (42830) and secondary (42835) adenoidectomy codes. How do we know what the differentiating factors are?

Delaware Subscriber

Answer: Sometimes tonsil or adenoid tissue grows back following a tonsillectomy or an adenoidectomy. That’s the source of the terms “primary” and “secondary” in the codes. The term “primary” refers to the initial removal of the tonsil or adenoid. “Secondary” refers to a second surgery to remove portions of the tonsil or adenoid missed during the primary procedure or which grew back subsequent to the primary procedure.

For a primary procedure on a patient younger than the age of 12, you’ll report 42830 (Adenoidectomy, primary; younger than age 12), and for the secondary version, you’ll submit the claim with 42835 (Adenoidectomy, secondary; younger than age 12).

Pay difference: CPT^® provides different codes for primary or secondary adenoid removal, each of which is tied to a different payment amount. That means you must determine from the surgeon’s documentation whether he performed a primary or secondary adenoidectomy. Billing a secondary adenoidectomy when the surgeon performed a primary could cost you pay — $15 to be exact (42830 pays $213 and 42835 pays $198 using the 2021 national Medicare Physician Fee Schedule.