Anesthesia Coding Alert

Question: Our physician noted "EUA [exam under anesthesia] control bleed" in the notes for a patient who returned to surgery because of tonsil bleeding. How should I code this procedure?

Alabama Subscriber

Answer: You have three procedure code choices for the patient's return to surgery:

• 42960 - Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple
• 42961 - ... complicated, requiring hospitalization
• 42962 - ... with secondary surgical intervention.

Each of these codes crosses to anesthesia code 00170 (Anesthesia for intraoral procedures, including biopsy; not otherwise specified). If the return to surgery was the same day as the original surgery, you must append either a -59 (Distinct procedural service) or one of the "X" modifiers (as applicable) to explain the separately billable anesthesia service with a diagnosis code for post-operative bleeding. Presuming the procedure was a tonsillectomy, you would report J95.830.