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CPT for ENT: Lingual Tonsillectomy (CPT 42870) and Adenoidectomy

CPT for ENT: Lingual Tonsillectomy (CPT 42870) and Adenoidectomy

Q: Can I report CPT 42870 Excision or destruction lingual tonsil, any method and the codes for adenoidectomy, CPT 42830, 42831, 42835, and 42836 on the same date-of-service? Can I report CPT 42870 Excision or destruction lingual tonsil, any method and the codes for tonsillectomy, CPT 42820 – 42826 on the same date-of-service?

A: No. Currently, CCI edits for CPT 42870 and CPT 42830, 42831, 42835, 42836 and 42820-42826 include an edit of “0”, meaning there are no circumstances in CMS’s view for which a modifier would be appropriate to enable a reporting of these two codes together. Further, use of a modifier to bypass the edit will not be recognized. The Academy opposed this edit, as we feel that these procedures are wholly distinct and unrelated.

However, despite Academy advocacy efforts—including two separate letters contesting these edits and explaining how the procedures are distinct, involve different anatomic sites, use different instruments, and have different clinical indications—CMS has opted to bundle CPT code 42870 into CPT codes describing adenoidectomy (CPT codes 42830-42836), tonsillectomy (CPT codes 42825, 42826), and combined tonsillectomy and adenoidectomy (CPT codes 42820, 42821).Unfortunately, CMS considers the adenoids, faucial tonsils, and lingual tonsils to reside in an anatomically related area. CPT code 42870 includes the “separate procedure” designation and CMS payment policy does not allow payment when the procedure described by that code is performed with another procedure in an anatomically related area. The CPT definition of “separate procedure” is quite different from CMS payer policy and to quote its description in 2015: “Some of the procedures and services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.”

The aforementioned information pertains to Medicare and may not apply to all carriers. Members are encouraged to review private carrier policies to determine if they follow Medicare.

Approved May 2015

 

Important Disclaimer Notice (Updated 8/7/14)

CPT for ENT articles are a collaborative effort between the Academy’s team of CPT Advisors, members of the Physician Payment Policy (3P) workgroup, and health policy staff. Articles are developed to address common coding questions received by the health policy team, as well as to clarify coding changes and correct coding principles for frequently reported ENT procedures. These articles are not intended as legal, medical, or business advice and are not a guarantee of reimbursement. The information is also not meant to serve as the definitive or sole authority on billing and coding issues. The applicability of AAO-HNS billing and coding guidance for a particular procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. You should consult with your own advisors as well as Medicare or private carriers in making any decisions about how to bill and code particular services or procedures.

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