" Although it is frequently performed and relatively straightforward, tonsillectomy may create billing problems, particularly for the inexperienced
otolaryngology coder.
Coders face unique challenges when distinguishing tonsillectomy from adenoidectomy (removal of the adenoids), uvulopalatopharyngoplasty (UPPP) and somnoplasty, any of which may be combined with tonsillectomy in the operating room.
The patient's postoperative condition (especially when there is postoperative bleeding), as well as a carrier's preauthorization requirements, also affects the coding process.
Tonsillectomy, removal of the palatine tonsils due to bacterial infection or hypertrophia, is reported as 42825 (tonsillectomy, primary or secondary; under age 12) or 42826 ( age 12 or over).
Adenoidectomy
Although adenoidectomy is often performed as a combined procedure with tonsillectomy and reported as 42820 (tonsillectomy and adenoidectomy; under age 12) or 42821 ( age 12 or over), the procedure is increasingly performed apart from tonsillectomy. Adenoidectomy helps children who have middle-ear diseases or infections, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's Editorial Panel and Executive Committee.
CPT 2002 identifies adenoidectomy as being either primary"" or ""secondary"":
" 42830 adenoidectomy primary; under age 12
42831 age 12 or over
42835 adenoidectomy secondary; under age 12
42836 age 12 or over.
Note: Coding Illustrated: Head and Neck defines "primary" as "the initial removal of the adenoid " whereas "secondary" is "to remove portions of the adenoid missed during the primary procedure."
Adenoidectomy may include myringotomy with tubes reported as 69433 (tympanostomy [requiring insertion of ventilating tube] local or topical anesthesia) or 69436 ( general anesthesia). It is important to make sure the correct diagnosis code is linked to the appropriate procedure Eisenberg says noting that the adenoidectomy is not performed in these cases because of adenoidal hypertrophy.
"You can't put down hypertrophy of the adenoids for the adenoidectomy because in this case it isn't accurate and you can't put down chronic mucoid otitis media (381.2x) or secretory otitis media (381.3) because these codes do not support an adenoidectomy and will be bumped out of the carrier's system and be denied " he says.
The appropriate otitis media code in these cases should be linked to the appropriate tympanostomy code while a diagnosis of chronic adenoiditis (474.01) should be associated with the adenoidectomy Eisenberg says.
Note: When adenoidectomy and tympanostomy are performed during the same session the procedures are reported from highest to lowest RVU value.
For example if the otolaryngologist performed a primary adenoidectomy and a tympanostomy under general anesthesia on a 7-year-old child 42830 would be reported first because it has been assigned more RVUs (5.26) than 69436 (4.15).
The carrier will apply multiple-procedure rules and reduce reimbursement for the tympanostomy 50 percent.
Uvulopalatopharyngoplasty (UPPP)
UPPP is used to treat patients [...]
