Otolaryngology Coding Alert

Question: One of our insurers has very strict guidelines for a T&A. Often times, the patient meets medical necessity and medical criteria for an adenoidectomy but doesn’t medical necessity for the tonsillectomy. Are we allowed to only report the adenoidectomy code (42830) to the insurance carrier despite the patient having a tonsillectomy and adenoidectomy performed? Or, should we unbundle the codes and report 42830 and then 42825 knowing that we will get a denial for the tonsillectomy?

Kentucky Subscriber

Answer: CPT® states that services must be coded with the code that most closely reflects the service(s) provided. Based on this rule, the correct way to code the services that were performed would be a T&A with 42820 (Tonsillectomy and adenoidectomy; younger than age 12) or 42821 (… age 12 or over). There is a good chance that the third party payer may deny the T&A based on what they pre-approved. If this happens, you should appeal the denial with the operative note, explaining that the tonsillectomy was performed because it was based on the clinical judgment of the surgeon. On appeal, the surgeon should be able to get paid for the approved adenoidectomy procedure.