Otolaryngology Coding Alert

Question: When reporting adenoidectomy with tonsillectomy, does it matter if the adenoidectomy is primary or secondary?

Massachusetts Subscriber

Answer: For adenoidectomy only (that is, adenoidectomy without tonsillectomy), you must determine from the surgeon's documentation whether he performed a primary or secondary adenoidectomy.

For primary adenoidectomy, you should report 42830 (Adenoidectomy, primary; under age 12) or 42831 (... age 12 or over), as appropriate for the patient's age. Similarly, for secondary adenoidectomy, you should claim either 42835 (Adenoidectomy, secondary; under age 12) or 42836 (... age 12 or over).

Consider that you may have to look to previous documentation to determine whether the surgeon previously removed adenoids that have grown back (secondary removal), or whether this is the first removal (primary removal).

Combo coding: If the surgeon performs both a tonsillectomy and adenoidectomy during the same surgery, you must use the combined tonsillectomy/adenoidectomy codes 42820 (Tonsillectomy and adenoidectomy; under age 12) and 42821 (... age 12 or over). If you were to report 42826 (for tonsillectomy) and 42836 (for secondary adenoidectomy) separately, for instance, you would be committing an unbundling error. Instead, you should report the single code 42821. So, it does not matter that the doctor is performing a secondary adenoidectomy when both a tonsillectomy and adenoidectomy are performed together.

Bottom line: Combined tonsillectomy/adenoidectomy codes 42820 and 42821 do not differentiate between primary and secondary adenoidectomy.