Wiki tonsillectomy with secondary adenoidectomy

[maebelle@gmail.com]

Needing some help with the coding of this surgery....we have a Medicaid patient that had a tonsillectomy and a secondary adenoidectomy (patient had previous surgery to remove adenoids). We have coded it several different ways. First we used the combination code of 42820 (patient is younger than 12) since this code does not differentiate between primary and secondary. Medicaid denied stating this is a "once in a lifetime" code. We then refiled the charges with separate codes for the T&A using 42825 (tonsillectomy younger than 12) and 42835 (adenoidectomy, secondary younger than 12). Medicaid denied it this way as well stating that these codes cannot be billed with each other because there is a combination code. Since we filed with the combination code first, we are not sure how to proceed with getting this paid. Does anyone have any suggestions?

Thanks!

 

[Thouvenel]

It would depend on the dictation and path I think. Were the adenoids really removed before, did they grow back or is this scar tissue? If the adenoids truly grew back, I would appeal with the op report and path report using the 42820.