Part B Insider (Multispecialty) Coding Alert

Published on Thu Nov 15, 2012 PDF

Secret: You can use 42820, 42821 as universal T&A codes.

Warning: You must know a patient's age and prior surgery status before you code tonsillectomy and adenoidectomy claims. Otherwise, you could be choosing the wrong code or even unbundling procedures.

Step 1: Check the Patient's Age

When coding for tonsillectomies and/or adenoidectomies, you should choose the appropriate code based on the patient's age.

CPT® contains two tonsillectomy codes, four adenoidectomy codes, and two combination codes - all of which separate at age 12.

For a child who is under the age of 12, you will use:

• 42820 -- Tonsillectomy and adenoidectomy; under age 12
• 42825 -- Tonsillectomy, primary or secondary; under age 12
• 42830 -- Adenoidectomy, primary; under age 12
• 42835 -- Adenoidectomy, secondary; under age 12.

When the patient is age 12 or older, you should assign:

• 42821 -- Tonsillectomy and adenoidectomy; age 12 or over
• 42826 -- Tonsillectomy, primary or secondary; age 12 or over
• 42831 -- Adenoidectomy, primary; age 12 or over
• 42836 -- Adenoidectomy, secondary; age 12 or over.

Warning: Prompt T&A payment depends on your selecting the right age-specific code. If you use 42820 on a 13-year-old child, the insurance company will deny the claim. Most payers' computer systems have claim edits in place that would drop a mismatched age and code claim from processing, experts say.

Step 2: Look for Primary, Secondary Adenoidectomy

If the otolaryngologist performs an adenoidectomy alone, you must also check the operative report to see whether the patient had a secondary adenoidectomy.

You should use 42830 or 42831 for a primary adenoidectomy. But if the patient has had adenoids previously removed, you should code a secondary adenoidectomy with 42835 or 42836. A secondary adenoidectomy removes the regrowth of the adenoids or any portion missed during the first procedure.

Coding example: An otolaryngologist removes portions of the adenoids that regrew after a 6-year-old patient's primary adenoidectomy. Because the surgeon performs a secondary procedure - and CPT® distinguishes between primary and secondary adenoidectomies - you should report this operation with 42835.

Watch out: Even though an otolaryngologist may perform a primary or secondary tonsillectomy, CPT® lumps both procedures into one code. Although the patient's medical record should reflect whether the patient previously had tonsils removed, you still use the same code.

Step 3: For T&A, Report 42820 or 42821

When coding for a combination T&A, you also don't have to distinguish whether the otolaryngologist performed a primary or secondary adenoidectomy.

Nowhere is 42820-42821 confined to primary or secondary patient types.

Use 1 Code to Describe Tonsillectomy and Primary or Secondary Adenoidectomy

If the otolaryngologist performs both tonsillectomy and adenoidectomy for the first or second time, you should report only 42820 or 42821. Insurers consider separately reporting the procedures with 42825/42835 unbundling, which is the biggest no-no, experts say.

Insurers will correct unbundling errors: Some insurance companies may re-bundle 42825 and 42835 together and paying the claim as 42820. The EOB states that 42820 should be used when a surgeon performs a T&A, regardless of whether the patient previously had adenoids removed. Other payers may outright deny the entire claim for unbundling, or may only pay one of the services, either the 42825 or 42835

Coding example: An otolaryngologist performs a T&A on a 10-year-old patient who previously had his adenoids removed. In this case, you should code the tonsillectomy and secondary adenoidectomy as a T&A under the age of 12 (42820).