Otolaryngology Coding Alert

Question: Our practice saw a patient who had badly bitten their tongue and lip following a dental procedure where they were administered local anesthetic. The provider packed the tongue and lip using a topical powder which subsequently stopped the bleeding. What’s the CPT^® code for this?

Iowa Subscriber

Answer: There are no existing codes in the CPT^® manual that you should report for the packing of a bleeding lip and/or tongue. Your closest option, code 42960 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple), is typically designated for instances of postsurgical bleeding of the soft palate, throat, tonsils, and back third of the tongue.

Instead of opting for a CPT^® code, the correct course of action is to include this service as a component of the evaluation and management (E/M) visit. Given that the patient presented with a single, minor, self-limited problem (“a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status” per CPT^® guidelines); the provider had no data to review or analyze; and the risk of complications and/or morbidity or mortality to the patient following treatment is minimal, the level of medical decision making (MDM) for the encounter would rise to a straightforward level. This would lead you to report 99202/99212 (Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) for the service.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC