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Coding Corner: Know the Patient's Age for Tonsil Procedure

And soothe sore payers with proper diagnostic backup

Physicians may perform tonsillectomies and adenoidectomies together or separately, but age always makes a difference in the code you'll report. Remember to distinguish between patients younger and older than 12, and the other choices will be a breeze.
Decide Who's on First for Adenoidectomies
When the physician removes only the patient's adenoids, you'll need to determine - in addition to the patient's age - whether the procedure was primary or secondary. "Primary" indicates an initial removal of the adenoids. "Secondary," on the other hand, refers to a removal of portions of the adenoid tissue that have regrown after the primary procedure, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc. in Lakewood, N.J. The secondary growth doesn't always happen, but it's unique enough to require a different code, she says.

CPT breaks both primary and secondary adenoidectomies down by age. For a primary operation in which the patient is younger than 12, you should report 42830 (Adenoidectomy, primary; under age 12). When the patient is 12 or older, use 42831 (... age 12 or over). For secondary procedures, you'll choose between 42835 (Adenoidectomy, secondary; under age 12) and 42836 (... age 12 or over).
Use a Single Code for Combined Procedure
You'll still have to pay attention to age when reporting combined tonsillectomy and adenoidectomy (T&A) - but you won't need to pay attention twice. Instead of reporting separate codes for the procedures, you'll just select one. Choose between 42820 (Tonsillectomy and adenoidectomy; under age 12) and 42821 (... age 12 or over) when the physician performs both procedures during the same session.

"You don't unbundle it," Cobuzzi says. "If you do both, you're going to bill the T&A - tonsillectomy and adenoidectomy. But there are times when a patient just has hypertrophied tonsils and not hypertrophied adenoids, and a doctor will just do a tonsillectomy. Or a patient will just have hypertrophied adenoids and not tonsils, and the doctor will do just an adenoidectomy," she says. "But if you do both of them, you bill the code that represents both of them."
Report the combined code only when the physician performs both procedures within one operative session, Cobuzzi says.
Lighten Your Load With Proper Diagnoses Codes
When billing one or both of these procedures, the diagnosis code you report should reflect the procedure the physician performs. For instance, physicians often remove the palatine tonsils due to repeat bacterial infection or hypertrophy. You should support this claim with a diagnosis that reflects tonsillitis, such as 463 (Acute tonsillitis) or 474.11 (Hypertrophy of tonsils alone).
You can support reimbursement for an [...]

- Published on 2004-02-09