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General Surgery Coding Alert

Consider Patient, Surgical Factors in Coding Tonsillectomy

Published on Mon Apr 01, 2002

General surgeons who perform tonsillectomies may find coding them particularly challenging, especially if they do not perform them regularly.
 
Patients who do not respond to antibiotic treatment of infected tonsils are frequently sent to an otolaryngologist or general surgeon to have them removed.
 
Patients may also be referred for tonsillectomy because the tonsils are hypertrophied and obstructing an airway, notes Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.
 
Several factors influence correct code selection:
 
Age of the Patient. Basic tonsillectomy is coded 42825 for those under age 12 and 42826 for those 12 or over.
 
Adenoidectomy. Adenoidectomy and tonsillectomy performed as a combined procedure is also coded according to age: 42820 for patients under 12 and 42821 for those 12 or over.
 
The surgeon may remove only the adenoids in some cases, calling for either a primary adenoidectomy or secondary one. Code these procedures as 42830 (Adenoidectomy, primary; under age 12), 42831 ( age 12 or over), 42835 (Adenoidectomy, secondary; under age 12) and 42836 ( age 12 or over).
 
Controlling Bleeding. Coding post-tonsillar or postadenoidal bleeds can be particularly confusing for general surgeons: These services have their own codes, even though it is exceedingly rare that a post-tonsillar or postadenoidal bleed would be treated after the original procedure's 90-day global period.  
 
"When the [post-tonsillar bleed] codes were created, it was understood that this service was performed shortly after a tonsillectomy, which has a 90-day global," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta. S.C. Codes for procedures designed to control post-tonsillar or postadenoidal bleeding include:
 
 42960 Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple
 
 42961 complicated, requiring hospitalization
 
 42962 with secondary surgical intervention
 
 42970 Control of nasopharyngeal hemorrhage, primary or secondary (e.g., postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery
 
 42971 complicated, requiring hospitalization
 
 42972 with secondary surgical intervention.
 
The same Medicare surgical package guidelines for treatment of postsurgical bleeds apply to post-tonsillar and postadenoidal hemorrhages. Part B carriers may not pay for 42960, 42961, 42970 or 42971, even though CPT included them specifically for the postoperative period, Callaway says. Medicare carriers will pay for 42962 or 42972 because these procedures are performed in the operating room.
 
Medicare's surgical package states that if a complication (such as a bleed) requires a return to the operating room, the service is paid separately and should be appended with modifier -78 (Return to the operating room for a related procedure during the postoperative period) to override the global edit.
 
"Private payers are more likely to pay separately for hemorrhage control that did not require a return to the operating room," Cobuzzi says, adding that the carriers may differ on how the procedures should be reported.
 
Some carriers may require the appropriate hemorrhage control code and nothing else, whereas others may require modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) or another modifier.

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