Anesthesia Coding Alert

Question: Our anesthesiologist provided general anesthesia during a morning surgery. Later that day, the patient started bleeding through the nose so the surgeon took her back to the operating room. His notes state "re-exploration nose for control of post-op bleeding" and he diagnosed "epistaxis." How should we code anesthesia for the return case (the same anesthesi­ologist handled both cases)?

Washington Subscriber

Answer: When a patient returns to the operating room for postoperative bleeding, your diagnosis and a modified procedure code should help explain the situation to the insurance company. Although the diagnosis in this scenario is indicated as epistaxis (R04.0), the more correct choice likely is postoperative bleeding from the previous surgery as the notes indicate "re-exploration nose."

Report the procedure with 00160 (Anesthesia for procedures on nose and accessory sinuses; not otherwise specified) and include modifier 59 (Distinct procedural service) to indicate the anesthesia was a separate service from the original procedure. If the payer denies the second claim, send a cover letter explaining the circumstances and copies of both anesthesia records with the times clearly indicated. Do not use a highlighter to indicate details, however, as it may black out the pertinent information if it is scanned.