Bundling Issue - Uvulopalatopharyngoplasty and Tonsillectomy

Bundling Issue - Uvulopalatopharyngoplasty and Tonsillectomy

Q: Can a uvulopalatopharyngoplasty (UPPP) Current Procedural Terminology (CPT code 42145) and a tonsillectomy (CPT code 42826) be billed at the same surgical session?

A: The Practice Management Department has noticed an increase in inquiries on the bundling of Tonsillectomy and Uvulopalatopharyngoplasty. Historically speaking, the codes for uvulopalatopharyngoplasty (CPT code 42145) and tonsillectomy (CPT code 42826) have been bundled in NCCI since 1/1/2002.

The American Academy of Otolaryngology Head and Neck Surgery tried to have the edit overturned without success. The Academy, drafted a letter to Administar Federal the contractor for the Center for Medicare / Medicaid Services (CMS) and its Correct Coding Initiative (CCI) to make clear that a tonsillectomy is a separate and distinct surgical procedure from the uvulopalatopharyngoplasty. Citing each requires the application of distinct surgical skills and judgment in addition to separate anatomic sites.

Many insurance carriers utilize editing software packages which bundle these procedures providing the rationale to the members that they are performed through the same incision. CMS decided to implement the edit with an effective date of 1/1/2002 not allowing the use of NCCI associated modifiers.

The American Academy of Otolaryngology – Head and Neck Surgery position remains unchanged. These are separate and distinct procedures. There are certain insurance carriers that have medical policies which allow billing both procedures at the same surgical session. A different diagnosis from that used for the UPPP (such as tonsil hypertrophy or chronic tonsillitis), if applicable, should be linked to the tonsillectomy.

You should consider contacting the insurance company to review if the carrier allows you to report both procedures together. When needed you may need to contact the Medical Director and explain the fact that these are separate and distinct procedures. Provide the specific details on how each procedure requires the application of distinct surgical skill and judgment in addition to separate anatomic sites. When both procedures must be performed together, CMS suggest that the -22 modifier be appended to (CPT code 42145). The local carrier will then have the opportunity to review the surgical report and increase payment appropriately.

When coding for a laser assisted uvulopalatopharyngoplasty, Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty (LAUP) CPT code 42145), should not be reported, this code is not intended to describe the laser procedure. Currently, the CPT code set does not have a specific code that accurately describes uvulopalatoplasty via laser technique; therefore, (CPT code 42299), Unlisted procedure, palate, uvula, should be reported.

When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time, effort, and equipment necessary to provide the service.

Keep in mind that each carrier makes its own individual determination and will inform you of the determination based upon the carrier’s medical policy. As always your Academy encourages you to review your contracted carrier’s medical policy for any limitations or restrictions to the reimbursement of the procedures when rendered at the same operative session.

Richard Waguespack, MD
AMA CPT Panelist and Chair, CPT & Relative Value CMTE

Charles F. Koopmann, JR., MD
Coordinator for Practice Affairs

Reviewed 8/03/06

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.