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Question: Our provider performed a primary tonsillectomy and a secondary adenoidectomy on an 8-year-old patient. Should I code both procedures separately using 42825 and 42835, or should I use the combination code 42820, even though it doesn’t stipulate primary and secondary for either procedure?

Vermont Subscriber

Answer: Even though the combination tonsillectomy/adenoidectomy (T&A) codes (42820-42821) do not distinguish between primary and secondary for either procedure, you cannot code a separate tonsillectomy code from 42825-42826 with a separate adenoidectomy code from 42830-42836.

That’s because Medicare’s National Correct Coding Initiative (NCCI) edits bundle the separate T&A code together with a modifier indicator of “0,” which means you cannot override the bundles with any modifier.

Consequently, if the surgeon performs a tonsillectomy and adenoidectomy at the same session, regardless of whether either procedure is primary or secondary, you must use the appropriate combination code: 42820 (Tonsillectomy and adenoidectomy; younger than age 12) or 42821 (… age 12 or over), depending on the patient’s age. In your example, that would mean using 42820 for the primary tonsillectomy and a secondary adenoidectomy on your 8-year-old patient.

Remember: “Primary” refers to the initial surgical removal of the tonsil or adenoid, while “secondary” refers to a subsequent surgery to remove portions of the tonsil or adenoid missed during the initial procedure or that grew back after the primary procedure.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC