Pathology/Lab Coding Alert
Tonsillectomy
Tamala Green
Sierra Pathology Associates, Reno, Nev.
Answer: As a first step to solve this dilemma, check with the physician office responsible for the tonsillectomy to ensure that the diagnosis code you are reporting is correct. Also, request an explanation of the denial from the carrier, to see if ICD-9 coding is the issue.
We have heard reports, however, that other practices, particularly in Wisconsin and Georgia, have experienced similar claim denials from a particular insurance carrier. Evidently, this carrier has characterized the gross examination of tonsils and adenoids as a hospital-mandated exam, for quality assurance.
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