Otolaryngology Coding Alert

Question: Using an adenoid curette instrument, a benign neoplasm is excised from the nasopharynx canal of a 15-year-old patient and subsequently biopsied. The adenoids are left intact. Since the entire mass is fully removed, can I bill out using 42831?

Wisconsin Subscriber

Answer: If the physician does not remove the adenoids, then billing for 42831 (Adenoidectomy, primary; age 12 or over) is incorrect, despite the proximity of the mass to the adenoids. Additionally, 42831 involves the removal of the adenoids in their entirety — so even if a partial adenoidectomy was necessary in order to excise the entire mass, billing for 42831 is still incorrect.

On the surface, you might consider one of these two codes:

• 42806 (Biopsy; nasopharynx, survey for unknown primary lesion)
• 42808 (Excision or destruction of lesion of pharynx, any method)

Initially, it might look appealing to bill them together. National Correct Coding Initiative (NCCI) edits allow for an overriding modifier on the column 2 code 42806, so what’s the harm? This example offers a valuable lesson in knowing when and when not to abuse modifier 59 (Distinct Procedural Service).

When NCCI gives you the option to override a bundle with modifier 59, your initial reaction might be to take advantage of the opportunity. However, these two procedures are “tentatively” bundled for a reason. According to NCCI you should, in most cases, include 42806 in 42808.

However, if the documentation explains that 42806 is performed for a separate medical purpose, the use of a modifier is allowed.

For example: If the lesion of unknown etiology is biopsied and the frozen section comes back as malignant, the surgeon may be required to go back in and fully remove the lesion. In this case, using modifier 59 is appropriate. Similarly, if one lesion in the nasopharynx is biopsied and another lesion is excised, modifier 59 is appropriate to append on both codes since the two procedures were performed on two different lesions.

Your scenario doesn’t meet the requirements for an overriding modifier. The biopsy and the excision are performed for the same medical purpose, so code 42808 includes the biopsy.