Otolaryngology Coding Alert

Question: Which code should I report when my otolaryngologist performs laser-assisted uvulopalato-plasty (LAUP)?

Arizona Subscriber

Answer: The answer depends on whether you're billing Medicare or a private payer. You may report 42145-52 (Palatopharyngoplasty [e.g., uvulopalato-pharyngoplasty, uvulopharyngoplasty]; reduced services) to commercial insurers. For Medicare, however, you should use the unlisted-procedure code 42299-GA (Unlisted procedure, palate, uvula; waiver of liability statement on file).

Don't report 42145-52 to your Medicare carriers. In a local medical review policy similar to many nationwide, Noridian (Part B carrier in Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming) states that this code combination is inappropriate and that it "could be considered fraudulent" to report 42145-52 for LAUP services.

Most Medicare carriers consider LAUP a non-covered service. "LAUP is not covered at this time, since it is not considered effective for obstructive sleep apnea," Noridian's LMRP states. You should therefore ask Medicare patients to sign an advance beneficiary notice before you perform the service. You should notify the patient that most Medicare carriers don't reimburse LAUP. Report 42299-GA to Medicare and list "LAUP" in item 19 on the CMS-1500 claim form or in field 5 for electronic claims.

The modifier informs the carrier that you have a signed ABN on file. That way, the patient's explanation of benefits will indicate that the insurer allows you to bill the patient directly. Check your carrier's policy to clarify exactly how you should submit LAUP claims.

Commercial payers' LAUP policies vary, but many private payers cover LAUP for sleep apnea patients. You should report 42145-52 to commercial payers. This code describes uvulopalatopharyngoplasty (UPPP). Because UPPP affects the pharynx and LAUP doesn't, you should append modifier -52 to 42145 to indicate that the otolaryngologist performs part of the procedure: palatoplasty, rather than pharyngoplasty.