Pediatric Coding Alert

Question: A patient reported to our office complaining of a sore throat and difficulty swallowing. After an exam, our pediatrician diagnosed the patient with a tonsil stone. Because of the patient’s gag reflex, our pediatrician used benzocaine spray to numb the tonsil before successfully removing the stone with a curette. I cannot find a code for this procedure, so do I code this as an evaluation and management (E/M) visit, or is there another way to report this?

Codify Subscriber

Answer: There is no CPT^® code that specifically describes what your pediatrician performed, but there is one that you can use with caution.

You can begin by documenting the E/M service. Report 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) linked to the patient’s symptoms: R07.0 (Pain in throat) and R13.10 (Dysphagia, unspecified). You’ll then append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to indicate that your pediatrician performed a separate service to remove the tonsil calculus.

The most appropriate code to report for that service would be 42999 (Unlisted procedure, pharynx, adenoids, or tonsils) linked to J35.8 (Other chronic diseases of tonsils and adenoids). But as this is an unlisted procedure, you will have to justify using it to your payer. This will require a letter to the payer explaining why the procedure was needed along with the appropriate notes from the procedure.

In addition, as unlisted codes carry no work relative value units (RVUs) and, therefore, no reimbursement fee, payers will often compare them to similar, established procedures in order to provide a reimbursement value for them.

Because of this, you can help your claim by providing a code that describes such a procedure. In this case, you could offer a code such as 42809 (Removal of foreign body from pharynx). While the code describes a procedure that is much more elaborate than the one your pediatrician performed, it is probably the closest listed code to the procedure performed. Being proactive and offering a comparison code may not get you the reimbursement you hope for, but it may just persuade your payer not to compare your services to a lower-paid procedure.