Otolaryngology Coding Alert

Question: When my otolaryngologist performs tonsillectomy on an adult Medicare patient who is undergoing uvulopalatopharyngoplasty (UPPP), may I report both procedures?

Ohio Subscriber Answer: Normally, you may not report tonsillectomy code 42826 (Tonsillectomy, primary or secondary; age 12 or over) in addition to UPPP (42145, Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). The National Correct Coding Initiative bundles 42826 into 42145. The edit contains a "0" modifier, which means Medicare doesn't allow modifier -59 (Distinct procedural service) to bypass the edit.
 
But look closely at the UPPP and tonsillectomy operating report. In some cases, you may use modifier -22 (Unusual procedural services) to indicate an unusual procedural service.
 
If the otolaryngologist's documentation justifies that the surgery required more time, specific skill and additional complexity than the normal 12-15 minutes a tonsillectomy adds to UPPP, you may append modifier -22 to the UPPP (42145) to represent the increased work.
 
As with any claims containing modifier -22, you should submit a paper claim. Include documentation showing the increased work that the procedure involved.