Reimbursement for partial tonsillectomy established in Germany

The reimbursement for the partial surgical removal of enlarged palatal tonsils has now been determined. Thus, contract physicians can bill this service from July 1, 2019. A decision to amend the Uniform Evaluation Scale (EBM) has been taken by the Valuation Committee. Contract doctors can now perform tonsillectomy for hyperplasia of the tonsils within the scope of the collective agreement. The Federal Joint Committee (G-BA) added the named treatment method to the list of statutory health insurance benefits last year.

With the decision of the Evaluation Committee, the procedure is included in Annex 2 of the EBM according to the procedure and procedure key (OPS) code 5-281.5 "Tonsillectomy (without adenotomy): Partial, transoral." At the same time, this OPS code is removed from the list of services that cannot or can no longer be reimbursed (Annex 4 to the EBM).

Tonsillectomy can now be reimbursed via the fee schedule item 31232 (1593 points / €172.40) or 36232 (877 points / €94.91) as an outpatient procedure or procedure performed by affiliated doctors. Based on the G-BA's sufficiently long follow-up after a tonsillectomy, the fee schedule item 31504 (743 points / €80.42) or 36504 (87 points / €9.47) falls under the interventions category N3.

The details were set by the G-BA in the number 28 of Annex I "Recognized examination or treatment methods" to the Directive on Contract Medical Care.

Thus, the partial surgical removal of enlarged palatine tonsils in patients over the age of the first year can be performed in cases of a symptomatic, clinically relevant impairment and when conservative treatment is insufficient. Only specialists in otolaryngology are allowed to perform the procedure.

The full details in German can be found here.

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