General Surgery Coding Alert

Question: Our surgeon removed tonsils and adenoids for a 6 year old patient. The op report notes excision of enlarged adenoids and tonsils. But the note also describes a large mass in the retropharyngeal space, and the surgeon extended the tonsil incision to dissect it out. The mass turned out to be a lymph node. Should we bill separately for the lymph node excision?

Utah Subscriber

Answer: The best answer is that you should not bill for a lymph node biopsy, such as 38500 (Biopsy or excision of lymph node(s); open, superficial) in this case. Removing the lymph node did not involve a separate site, incision, or session, which might indicate a separate service. Instead, you should probably judge this as an incidental lymph node.

You should bill this case as 42820 (Tonsillectomy and adenoidectomy; younger than age 12). If the physician’s documentation demonstrates increased time and complexity of the case, you might append modifier 22 (Increased procedural service).