Otolaryngology Coding Alert

Otolaryngologists often treat obstructive sleep apnea by performing a uvulopalatopharyngoplasty (UPPP), but face denials when they bill for the procedure. By vigorously appealing these denials with supporting documentation, physicians can ensure proper reimbursement.

UPPP (42145, palatopharyngoplasty, e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) is performed for a variety of reasons, most commonly snoring (786.09, dyspnea and respiratory abnormalities, other); upper airway resistance syndrome (780.56, dysfunctions associated with sleep stages or arousal from sleep) and/or obstructive sleep apnea (780.57, other and unspecified sleep apnea). The procedure also may be performed on patients with malignant lesions of the hard or soft palate or uvula (145.2, malignant neoplasm of other and unspecified parts of the mouth, hard palate; 145.3, soft palate; 145.4, uvula; 145.5, palate, unspecified, junction of hard and soft palate, roof of mouth) or benign lesions (210.4, benign neoplasm, palate [hard], [soft], uvula).

UPPP involves removing elongated and excessive tissues of the uvula, soft palate and pharynx. Incisions are made in the soft palate mucosa, and a wedge of mucosa is excised. Excessive submucosal tissue is then removed, and the uvula is excised. After the midline of the uvula is sutured, the otolaryngologist closes the remaining mucosa in a single layer, which increases the diameter of the oropharynx.

UPPPs and Tonsillectomies

When performing this procedure, the otolaryngologist often will perform a tonsillectomy because the tonsils are hypertrophied or inflamed or because the patient has chronic tonsillitis. Healthy tonsils typically are not removed during a UPPP.

Many commercial carriers routinely deny tonsillectomy claims when performed with UPPP, stating the tonsil removal is incidental to the primary procedure. These denials should be appealed vigorously, coding experts say. And an important weapon in the appeals arsenal should be letters and policy statements from professional societies such as the American Medical Association (AMA) and the American Academy of Otolaryngologists-Head and Neck Surgery (AAO-HNS) that support the otolaryngologists position.

The professional societies blame the software commercial carriers use for what they consider inappropriate bundling. Many medical carriers are utilizing software packages that rebundle CPT codes. One of the more common practices is to deny the payment for tonsillectomy when done in conjunction with UPPP on the basis that they are performed through the same incision, says Michael D. Maves, MD, MBA, immediate past executive vice president of AAO-HNS. Maves calls the bundling of these two procedures an arbitrary and capricious decision on the part of the medical carrier.

According to an AAO-HNS policy statement, A tonsillectomy and UPPP are separate and distinct surgical procedures. Each requires the application of distinct surgical skills and judgment to separate anatomic sites. Each of these surgeries entails separate surgical risks. When done together, each procedure would be (1) identified by its distinct CPT code, [...]