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Take the Hurt Out of Tonsillectomy Coding in Just 3 Steps

Postsurgery control of bleeding may call for its own code
When reporting tonsillectomy, you must consider three main factors: the patient’s age, whether the surgeon performed adenoidectomy, and whether the surgeon controlled post-tonsillar or postadenoidal bleeding during the 90-day global period of the original procedure.

1. Start With the Patient’s Age

When choosing tonsillectomy and/or adenoidectomy codes, remember that 12 is the magic number. That’s because CPT assigns different codes for patients younger than 12 years of age and those 12 years old or older, says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, speaker, physician and coding educator, and healthcare consultant in Camden, S.C.
Example: For a 14-year-old patient who has had tonsillectomy, you would report 42826 (Tonsillectomy, primary or secondary; age 12 or over). For an 11-year-old patient undergoing the same procedure, you would report 42825 (... younger than age 12).

2. Watch for Adenoidectomy

For adenoidectomy only (that is, adenoidectomy without tonsillectomy), you must determine from the surgeon’s documentation whether he performed a primary or secondary adenoidectomy, Dunaway says.
For primary adenoidectomy, report 42830 (Adenoidectomy, primary; younger than age 12) or 42831 (... age 12 or over), as appropriate for the patient’s age. Similarly, for secondary adenoidectomy, you should claim either 42835 (Adenoidectomy, secondary; younger than age 12) or 42836 (... age 12 or over).
Consider that you may have to look to past documentation to determine whether the surgeon previously removed adenoids that have grown back (secondary removal), or whether this is the first removal (primary removal).
Caution: If the surgeon performs both a tonsillectomy and adenoidectomy during the same surgery, you must use the combined tonsillectomy/adenoidectomy codes 42820 (Tonsillectomy and adenoidectomy; younger than age 12) and 42821 (... age 12 or over). If you report 42826 (for tonsillectomy) and 42836 (for secondary adenoidectomy) separately, for instance, you would be committing an unbundling error, Dunaway says. Instead, you should report the single code 42821.
Note: The combined tonsillectomy/adenoidectomy codes 42820 and 42821 do not differentiate between primary and secondary adenoidectomy.
APC classification: All tonsillectomy/adenoidectomy codes (42825, 42826, 42830, 42831, 42835 and 42836) fall into APC category 00258, with total outpatient reimbursement of about $1,400, under average Medicare national payments.

3. Report Control of Bleeding Cautiously

When the surgeon controls post-tonsillar or post-adenoidal bleeding during the surgery’s global period, you may be able to charge separately for the service.
CPT supplies six codes to describe post-tonsillar or postadenoidal bleeding:

• 42960 -- Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple (APC 00250)
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- Published on 2007-10-25