Part B Insider (Multispecialty) Coding Alert

Tip: Scrutinize descriptor details to know what you can’t submit together.

The latest Correct Coding Initiative (CCI) edits are worth paying attention to because they focus on some very common procedures: tonsillectomies and adenoidectomies.

Start With Understanding the Procedures

Tonsillectomy – completely removing the tonsil, including its capsule – is one of the most common surgical procedures in the U.S. Surgeons might also remove the patient’s adenoids at the same time, especially in relation to sleep-disordered breathing. Stand-alone adenoidectomies have increased in frequency in recent years as a method of helping children who have middle ear diseases or infections.

Some codes related to tonsillectomy and adenoidectomy refer to “primary” or “secondary” procedures. 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.

Surgeons have three options when performing these surgeries: tonsillectomy alone, adenoidectomy alone, or tonsillectomy with adenoidectomy.

Cross Check the Newest Edits

CCI 21.1, effective April 1, includes twelve edits associated with tonsillectomy and adenoidectomy. They each make sense when you compare the descriptors for each code pair, because the service of the Column 1 code obviously includes the work of the Column 2 code. 

For example, you report 42820 (Tonsillectomy and adenoidectomy; younger than age 12)  for a child who undergoes T&A during a single session. CCI now clarifies that you cannot report 42826 (Tonsillectomy, primary or secondary; age 12 or over), 42831 (Adenoidectomy, primary; age 12 or over), or 42836 (Adenoidectomy, secondary; age 12 or over) with the overriding procedure 42820. 

Explanation: Code 42820 specifies that the patient is younger than age 12, but codes 42826, 42831, and 42836 are all for a patient age 12 or over. The age disparity keeps you from reporting the codes together. In addition, because 42820 includes both tonsillectomy and adenoidectomy, you cannot report it with 42831 or 42836 for adenoidectomy.

The other edits follow a similar logic when you compare descriptors:

• Column 1 code 42821 (Tonsillectomy and adenoidectomy; age 12 or over) includes the work of 42835 (Adenoidectomy, secondary; younger than age 12).

• Code 42825 (Tonsillectomy, primary or secondary; younger than age 12) is reported instead of 42830 (Adenoidectomy, primary; younger than age 12), 42831 (Adenoidectomy, primary; age 12 or over), 42835, and 42836 when performed during the same session.

• Code 42826 (Tonsillectomy, primary or secondary; age 12 or over) overrides primary and secondary adenoid procedures 42830, 42831, 42835, and 42836.

Each of the edit pairs carries a modifier indicator of “0,” or “not allowed.” According to CMS, a “0” indicator means that “There are no modifiers associated with NCCI that are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid for the same beneficiary on the same day by the same provider.”

“To me, you cannot ever code these together because either the patient is 12 years old or over, or the patient is younger than 12,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “She can’t be both, so the descriptors will never coexist.”