Wiki Cpt code for epiglottopexy?

[AN2114]

I have been doing so much research on a code for epiglottopexy but I'm not having much success. I read that an epiglottopexy is done in a supraglottoplasty procedure. I usually use cpt code 31561 for a supraglottoplasty but I felt it may not be appropriate since it says laryngoscopy, direct, operative, with arytenoidectomy and he did not do an arytenoidectomy. The doctor also did a lingual tonsillectomy. I read that sometimes an epiglottopexy is done during a lingual tonsillectomy so is it inclusive to cpt code 42870? I don't want to under code but I also don't want to use an inappropriate cpt code.

After the doctor does the lingual tonsillectomy he says "a small area of ablation was then placed on lingual surface of epiglottis with the intention to slightly scare the epiglottis anteriorly to provide a more open airway." He also says in the beginning of the ope report "the epiglottis was retroflexed and displaced anteriorly due to enlarged lingual tonsils, this is causing mild obstruction." So like I said I don't want to under code or code inappropriately. Any suggestions??

 

[b.cobuzzi]

I think that only the Lingual tonsillectomy can be coded based on the documentation. If the doctor documented more for the epiglottis, I would consider putting a 22 modifier for increased service on the lingual tonsillectomy, but it does not look like you have enough to support the 22 modifier. Remember that since we are asking for more money with a 22 modifier, the documentation goes to the payer for review, so the support for more than 25% more complicated than a normal lingual tonsillectomy needs to be supported in the op note.

 

[AN2114]

I think that only the Lingual tonsillectomy can be coded based on the documentation. If the doctor documented more for the epiglottis, I would consider putting a 22 modifier for increased service on the lingual tonsillectomy, but it does not look like you have enough to support the 22 modifier. Remember that since we are asking for more money with a 22 modifier, the documentation goes to the payer for review, so the support for more than 25% more complicated than a normal lingual tonsillectomy needs to be supported in the op note.

Thank you!