Otolaryngology Coding Alert

When an otolaryngologist discovers and excises a retropharyngeal lymph node while performing a tonsillectomy, expectations of additional reimbursement may be inflated. If the node removal was performed without, say, an additional incision, the physician may not be able to bill a separate procedure but bill only for unusual circumstances, says Randa Blackwell, a coding specialist with the Department of Otolaryngology at the University of Maryland in Baltimore.

During a recent session in the operating room, an otolaryngologist performed a bilateral tympanotomy and a T&A. During the course of the tonsillectomy, a retropharyngeal lymph node also was excised. A coder on the physicians staff contacted Otolaryngology Coding Alert to ask how the lymph node excision should be billed and included the physicians operative report, which follows.

Pre-Op Diagnosis: Chronic serous otitis and T&A hypertrophy.

Post-Op Diagnosis: Chronic serous otitis and T&A hypertrophy. Large retropharyngeal lymph node.

Procedure: Bilateral tympanotomy and tube. T&A and excision of retropharyngeal lymph node.

Findings: The patient had enlarged adenoids and huge tonsils but when we removed the tonsils there was a large mass in the retropharyngeal space just to the right of the midline. At first I thought it was an anomalous carotid artery but on palpation there was no pulsation. It was a round movable mass, fairly firm. I suspected it was a lymph node but it could have been some kind of neurogenic tumor or something of that nature.

We elected while we were in there to go ahead and excise it. We simply extended the tonsil incision and developed a retropharyngeal flap and dissected out a lymph node that was about 1.5 cm in diameter. It seemed benign. It was smooth. It did not look like a tumor. We sent it as a separate specimen. I closed the retropharyngeal flap to the posterior edge of the tonsil incision with interrupted chromic sutures. The bleeding was minimal. There was no sign of any large vessels, such as a carotid artery in the area. She tolerated the procedure well.

(Editors note: The remainder of the note covered post-op care and is omitted here.)

The correct coding for this OR session is:

69436: tympanostomy (requiring insertion of ventilating tube), general anesthesia; ICD-9

381.10 (chronic serious otitis media, simple or unspecified).

42821: tonsillectomy and adenoidectomy, age 12 or
over; ICD-9 474.10 (hypertrophy of tonsils and adenoids). 210.9 (Benign neoplasm, pharynx, unspecified).

No separate CPT code should be billed for this lymph node excision because according to the operative report, the physician saw the mass after removing the tonsils, simply extended the incision and removed the nodes, says Blackwell. But modifier -22 (unusual procedural services) might be added if the procedure was complicated by [...]