Tonsils / UPPP Revisited

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Question:  

I was recently speaking to a colleague about reporting CPT codes 42826 and 42145 together when both a tonsillectomy and UPPP are performed. My colleague said they should be reported together when performed but when I looked at the CCI edits they are bundled. I told her that I could not report both codes because of the CCI edit. She disagreed and said I should report both if performed. Now, I am confused and unsure how I should report this if both services are performed at the same setting.

Answer:

We certainly understand your dilemma. In this scenario we agree with your friend. The following is a response to the same question posted in the AMA CPT Assistant in August 1997.

“AMA Comment

From a CPT coding perspective, the tonsillectomy is a separate and distinct procedure. Therefore, if the physician performs a palato-pharyngoplasty and a tonsillectomy, both services would be reported. In this instance, the modifier -51 should be appended to the secondary or additional procedure to indicate that multiple procedures were performed on the same day or at the same surgical session by the same physician”

Remember, the coding rules are written by the American Medical Association while Medicare CCI edits are payment rules for Part B Medicare. Medicare does not include every possible code combination in the CCI edits, thus you could actually code incorrectly if you only reported services based on Medicare CCI edits.

CCI edits are created and reversed each quarter, thus trying to code accurately based on CCI would be challenging. KZA and the AAOHNS recommend reporting services based on the AMA CPT rules to ensure coding compliance and accurate reporting of services.