Otolaryngology Coding Alert

"Secret: You can use 42820, 42821 as universal T&A codes If you don't know when a patient's age and prior surgery status affect tonsillectomy and adenoidectomy coding, you could be choosing the wrong code or even unbundling procedures. Step 1: Check the Patient's Age When coding for tonsillectomies and/or adenoidectomies, you should choose the appropriate code based on the patient's age.
 
CPT contains two tonsillectomy codes, four adenoidectomy codes, and two combination codes - all of which separate at age 12.
 
For a child who is under age 12, you will use:
  42820 - Tonsillectomy and adenoidectomy; under age 12
  42825 - Tonsillectomy, primary or secondary; under age 12
  42830 - Adenoidectomy, primary; under age 12
  42835 - Adenoidectomy, secondary; under age 12.  When the patient is age 12 or older, you should assign:
   42821 - Tonsillectomy and adenoidectomy; age 12 or over
  42826 - Tonsillectomy, primary or secondary; age 12 or over
  42831 - Adenoidectomy, primary; age 12 or over
  42836 - Adenoidectomy, secondary; age 12 or over. Warning: Prompt T&A payment depends on your selecting the right age-specific code. If you use 42820 on a 13-year-old child" the insurance company will deny the claim " says Eileen Antico CPC an otolaryngology coding specialist at Nemours Clinical Management Program (12 otolaryngologists) in Orlando Fla. "Most payers' computer systems have claim edits in place that would drop a mismatched age and code claim from processing."
 
Step 2: Look for Primary Secondary Adenoidectomy If the otolaryngologist performs an adenoidectomy alone you must also check the operative report to see whether the patient had a secondary adenoidectomy.
 
You should use 42830 or 42831 for a primary adenoidectomy. But if the patient has had adenoids previously removed you should code a secondary adenoidectomy with 42835 or 42836. "A secondary adenoidectomy removes the regrowth of the adenoids or any portion missed during the first procedure " Antico says.
 
Coding example: An otolaryngologist removes portions of the adenoids that regrew after a 6-year-old patient's primary adenoidectomy. Because the surgeon performs a secondary procedure - and CPT distinguishes between primary and secondary adenoidectomies - you should report this operation with 42835.
 
Watch out: Even though an otolaryngologist may perform a primary or secondary tonsillectomy CPT lumps both procedures into one code. Although the patient's medical record should reflect whether the patient previously had tonsils removed you still use the same code.
 
Step 3: For T&A Report 42820 or 42821 When coding for a combination T&A you also don't have to distinguish whether the otolaryngologist performed a primary or secondary adenoidectomy.
 
"Nowhere is [42820-42821] confined to primary or secondary patient types " says Andrew Borden CCS-P CPC CMA reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin [...]