Tonsillectomy with UPPP

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June 26, 2014

Question:  

Is it OK to bill for tonsillectomy and a UPPP separately? Most of the payers deny this as a bundled service when the two codes are submitted together.

Answer:

Yes, per the AMA’s CPT coding guidelines and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), these are separate and distinct procedures that can be coded and billed together when performed at the same surgical session. However, some payers, including Medicare, have an edit that does not allow payment for both at the same time. Unfortunately, CPT coding rules and payer edits do not always match. Although it is correct to bill for both procedures per CPT coding rules, getting paid may be another issue.

You may be able to obtain reimbursement for both procedures on appeal. Make sure to draft a letter explaining that the procedures are performed on distinct anatomic sites which should allow for separate payment.

If you are billing both procedures, and documentation supports the use of two different diagnosis codes, submit the tonsillectomy with a diagnosis code of chronic tonsillitis or tonsil hypertrophy and a separate diagnosis code for the UPPP. This will help to indicate the medical necessity for both procedures.