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 postop bleeding" and he diagnosed "epistaxis." How should we code anesthesia for the return case (the same anesthesiologist handled both cases)?

Answer: When a patient returns to the operating room for post operative bleeding, your diagnosis and a modified procedure code should help explain the situation to the insurance company. Although the diagnosis is indicated as epistaxis, the more correct choice likely is post-operative bleeding (998.11) 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.