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 (eg, 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 modifier 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 (Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure).