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General Surgery Coding Alert

Take the Hurt Out of Tonsillectomy Coding in Just 3 Steps

Published on Wed Mar 09, 2005

Postsurgery control of bleeding may call for its own code

When reporting tonsillectomy, you must consider three main factors: the patient's age, whether the surgeon performed adenoidectomy, and whether the surgeon controlled post-tonsillar or postadenoidal bleeding during the 90-day global period of the original procedure.

1. Look for the Patient's Age

When choosing tonsillectomy and/or adenoidectomy codes, remember that 12 is the magic number. That's because CPT assigns different codes for patients younger than 12 years of age and those 12 years old or over, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C.

For instance: For a 14-year-old patient who has had tonsillectomy, you would report 42826 (Tonsillectomy, primary or secondary; age 12 or over). For an 11-year-old patient undergoing the same procedure, however, you would report 42825(...under age 12).

2. Watch for Adenoidectomy

For adenoidectomy only (that is, adenoidectomy without tonsillectomy), you must determine from the surgeon's documentation whether he performed a primary or secondary adenoidectomy, Dunaway says.

For primary adenoidectomy, report 42830 (Adenoidectomy, primary; under age 12) or 42831 (...age 12 or over), as appropriate for the patient's age. Similarly, for secondary adenoidectomy, you should claim either 42835 (Adenoidectomy, secondary; under age 12) or 42836 (... age 12 or over).

Consider that you may have to look to previous documentation to determine whether the surgeon previously removed adenoids that have grown back (secondary removal), or whether this is the first removal (primary removal).

Caution: If the surgeon performs both a tonsillectomy and adenoidectomy during the same surgery, you must use the combined tonsillectomy/adenoidectomy codes 42820 (Tonsillectomy and adenoidectomy; under age 12) and 42821 (...age 12 or over). If you were to report 42826 (for tonsillectomy) and 42836 (for secondary adenoidectomy) separately, for instance, you would be committing an unbundling
error, Dunaway says. Instead, you should report the single code 42836.

Note: The combined tonsillectomy/adenoidectomy codes 42820 and 42821 do not differentiate between primary and secondary adenoidectomy.

3. Report Control of Bleeding Cautiously

When the surgeon controls post-tonsillar or post-adenoidal bleeding during the global period of the surgery, you may be able to charge separately for the service for non-Medicare payers that follow AMA guidelines.

CPT supplies six codes to describe post-tonsillar or postadenoidal bleeding:

  • 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 AMA designed 42960-42972 knowing that surgeons would use the codes during the postoperative period, and CPT guidelines dictate, "Postoperative complications ... are not included in the surgical package. ... Postoperative complications included conditions such as wound dehiscence, infection and bleeding."

    Translation: For payers that follow AMA guidelines, you should report 42960-42972 separately.

    For example: An 11-year-old patient undergoes primary tonsillectomy and adenoidectomy. Four days later, the surgeon must treat the child in the office for post-operative bleeding in the area of the nose and throat.

    In this case, you should report 42820 for the tonsillectomy/adenoidectomy and report 42970 for the control of bleeding. Append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to the follow-up procedure (42970) to indicate that this was an unrelated procedure during the global period of the tonsillectomy/adenoidectomy. The payer should recognize and reimburse for both codes.

    NCCI Payers Require Return to OR

    Because Medicare does not follow the CPT surgical package for complicated postoperative care, you should not report 42960 or 42970 (control of bleeding) for Medicare payers. These are simple procedures, usually performed in the surgeon's office - and Medicare bundles all care of postoperative complications that do not require a return to the OR, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

    For instance: The example is the same as above (11-year-old with tonsillectomy/adenoidectomy and post-surgical bleed), but the payer is Medicare.
     
    In this case, you can only report 42820. If you attempt to report 42970 in the postoperative period, the payer will reject the second claim as bundled to the first because it does not require a return to the OR.

    Medicare will, however, allow payment for post-operative complications that require a return to the OR, Bucknam says. Therefore, if the surgeon must perform the procedures described by 42961, 42962, 42971 or 42972 (all of which may require a return to the operating room), you may report the appropriate code separately with the tonsillectomy and adenoidectomy codes.

    You must, however, append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the follow-up procedure to override the edits that bundle 42961, 42962, 42971 and 42972 to 42820-42836.

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