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Adenoidectomy Description Unilateral?

Camille Posted Sat 07th of December, 2019 16:46:15 PM
Provider performs planned Tonsillectomy and Adenoidectomy. First describes a complete tonsillectomy (both tonsils). Does the following Operative Note excerpt describe only a unilateral adenoidectomy though? "A red rubber catheter was then placed through the nares, brought out through the mouth with elevation of the soft palate. Using a mirror, the adenoid pad was visualized, found to be hypertrophied and was taken down with suction cautery. Topical anesthetic was then place in the tonsillar fossae bilaterally. Additional hemostasis achieved with suction cautery. No further bleeding was noted..." Thank you very much!
SuperCoder Answered Mon 09th of December, 2019 01:26:56 AM

Hi Camille,

 

Tonsillectomy and adenoidectomy specific codes are assumed as bilateral procedure surgery codes. Therefore, it is not appropriate to append modifier 50 to any of the tonsillectomy or adenoidectomy codes (42820-42836).

 

Per submitted documentation, it does not clearly indicate that procedure was performed bilaterally. Hence it would be appropriate to append modifier 52 (i.e. for reduced services) to the CPT code when performed unilaterally (eg, unilateral adenoidectomy).

 

Thanks!

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