General Surgery Coding Alert

Postsurgery control of bleeding may call for its own code When reporting tonsillectomy, you must consider three main factors: the patient's age, whether the surgeon performed adenoidectomy, and whether the surgeon controlled post-tonsillar or postadenoidal bleeding during the 90-day global period of the original procedure. 1. Look for the Patient's Age When choosing tonsillectomy and/or adenoidectomy codes, remember that 12 is the magic number. That's because CPT assigns different codes for patients younger than 12 years of age and those 12 years old or over, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C.

For instance: For a 14-year-old patient who has had tonsillectomy, you would report 42826 (Tonsillectomy, primary or secondary; age 12 or over). For an 11-year-old patient undergoing the same procedure, however, you would report 42825(...under age 12). 2. Watch for Adenoidectomy For adenoidectomy only (that is, adenoidectomy without tonsillectomy), you must determine from the surgeon's documentation whether he performed a primary or secondary adenoidectomy, Dunaway says.

For primary adenoidectomy, report 42830 (Adenoidectomy, primary; under age 12) or 42831 (...age 12 or over), as appropriate for the patient's age. Similarly, for secondary adenoidectomy, you should claim either 42835 (Adenoidectomy, secondary; under age 12) or 42836 (... age 12 or over).

Consider that you may have to look to previous documentation to determine whether the surgeon previously removed adenoids that have grown back (secondary removal), or whether this is the first removal (primary removal).

Caution: If the surgeon performs both a tonsillectomy and adenoidectomy during the same surgery, you must use the combined tonsillectomy/adenoidectomy codes 42820 (Tonsillectomy and adenoidectomy; under age 12) and 42821 (...age 12 or over). If you were to report 42826 (for tonsillectomy) and 42836 (for secondary adenoidectomy) separately, for instance, you would be committing an unbundling
error, Dunaway says. Instead, you should report the single code 42836.

Note: The combined tonsillectomy/adenoidectomy codes 42820 and 42821 do not differentiate between primary and secondary adenoidectomy. 3. Report Control of Bleeding Cautiously When the surgeon controls post-tonsillar or post-adenoidal bleeding during the global period of the surgery, you may be able to charge separately for the service for non-Medicare payers that follow AMA guidelines.

CPT supplies six codes to describe post-tonsillar or postadenoidal bleeding:

42960 - Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple

42961 - ... complicated, requiring hospitalization

42962 - ... with secondary surgical intervention

42970 - Control of nasopharyngeal hemorrhage,  primary or secondary (e.g., postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery

42971 - ... complicated, requiring hospitalization

42972 - ... with secondary surgical intervention. The AMA designed 42960-42972 knowing that surgeons would use the codes during the postoperative period, and CPT guidelines dictate, "Postoperative complications ... are not included in [...]