Outpatient Facility Coding Alert

Published on Wed Mar 20, 2013 PDF

Question: What CPT^® code is appropriate for tissue welding tonsillectomy? Can I use code 42826 with modifier 22 or should I use unlisted code? And, can we use modifier 22 for Facility/ASC billing?

New Hampshire Subscriber

Answer:  A tonsillectomy can be performed by cryotherapy, laser, or electrocautery methods. Choose code 42825 (Tonsillectomy, primary or secondary; younger than age 12) or 42826 (… age 12 or over), depending on the patient’s age. The method the surgeon chooses doesn’t affect the code. 

Modifier 22 (Unusual procedural service) is not allowed for facility or ASC billing. Coders can sometimes report modifier 22 in other places of service when the work required to perform a procedure is substantially greater than typically required. When modifier 22 is appropriate, you must have sufficient documentation to support reporting modifier 22 for additional work and to explain the reason for the additional work (such as increased intensity, time, technical difficulty of procedure, severity of patient’s condition, or physical and mental effort required).