Otolaryngology Coding Alert

Otolaryngologists who review Correct Coding Initiative version 8.0 (CCI 8.0) may be disappointed to find that the CCI now bundles tonsillectomy 42826 (tonsillectomy, primary or secondary; age 12 or over) with uvulopalatopharyngoplasty (UPPP) 42145 (palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) and gives the edit a "0" indicator (i.e., physicians cannot append a modifier to 42826 to bypass the edit).
 
Note: Otolaryngologists may also be dismayed to find that UPPP pays slightly less in 2002 (16.02 RVUs) than in 2001 (16.49 RVUs). The cut in the 2002 Medicare fee schedule conversion factor, coupled with the reduced RVU rate, means that otolaryngologists will receive much less for UPPP than they received in the past.
The Bundling Debate
Otolaryngologists have long insisted that tonsillectomy and UPPP not be bundled since tonsillectomy is not always performed during UPPP, says Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wash. Although the otolaryngologist would probably remove inflamed or hypertrophied tonsils during UPPP, she says that the otolaryngologist may decide to leave healthy or small tonsils in place. "Otolaryngologists do not routinely remove tonsils when performing UPPP these days," Thompson says. 
 
Medicare appears to be using the new edit to say that tonsillectomy with UPPP should be standard medical practice, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "The people in charge of the CCI apparently have come to believe that tonsillectomy is performed with UPPP often enough to make it incidental," Callaway says.
 
Although most Medicare carriers have been paying separately for tonsillectomy and UPPP performed during the same session, many commercial carriers had stopped paying separately for tonsillectomy long ago on the grounds that tonsillectomy is incidental to UPPP. Bundling tonsillectomy with UPPP, therefore, means not only that Medicare will no longer pay separately for tonsillectomy and UPPP performed during the same session but also that private payers will be able to use the edit to justify their denials.
Reimbursement Strategies
Unusual Circumstances. It is possible to obtain reimbursement for a tonsillectomy performed at the same time as a UPPP, but only in unusual circumstances, Callaway says.
 
A morbidly obese patient with unusually small tonsils and a small mouth, for example, may require the otolaryngologist to reposition the tongue blade from one area to the next so as to see the tonsils in their entirety. In this case, it may be appropriate to append modifier -22 (unusual procedural services) to 42145 to indicate that the procedure took much more time and effort than normal. "The otolaryngologist must document that the removal of the tonsils [...]