Otolaryngology Coding Alert

Post-tonsillar bleeds are controlled during the global period of another procedure. This can make billing such procedures difficult, because no comprehensive or authoritative guidelines satisfy all payers. Although most private carriers pay separately for control of post-tonsillar bleeds even if a trip to the operating room is not required, Medicares global surgery guidelines include such complications. Local Medicare carriers vary in their policies, however, as do private insurers, which makes provider-insurer communication vital to gaining reimbursement for these procedures.

Complexity Determines Proper Coding

Post-tonsillar bleeds, or oropharyngeal hemorrhages, usually occur as a complication of surgery, most frequently tonsillectomy, but also uvulopalatopharyngoplasty (UPPP) and other procedures. The bleed may be either primary occurring within the first 24 hours after surgery or secondary beginning days after the primary procedure.

CPT includes three codes for control of a post-tonsillar bleed, each describing progressive levels of complexity:

42960 control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; simple
42961 complicated, requiring hospitalization and
42962 with secondary surgical intervention.

If, for example, a patient who is six days post-tonsillectomy bleeds from the right tonsil fossa and the otolaryngologist sees the patient in the office (or the emergency department [ED]) to control the bleeding, the appropriate code is 42960.

Code 42961 describes a more complicated encounter. For example, there may be a concern about blood loss if attempts to stop the bleeding in a hypotensive patient have failed, and the otolaryngologist may admit the patient to the hospital to control the problem.

Code 42962 correctly describes a situation in which the otolaryngologists attempts to control the bleeding remain unsuccessful, and the patient must return to the operating room for further surgery.

Note: CPT includes similar codes (42970, control of nasopharyngeal hemorrhage, primary or secondary [e.g., postadenoidectomy]; simple, with posterior nasal packs, with or without anterior packs and/or cauterization; 42971, complicated, requiring hospitalization; and 42972, with secondary surgical intervention) for the control of bleeding that may be performed after an adenoidectomy. Such procedures are performed less frequently than those following a tonsillectomy or UPPP.

Understand Billing Issues and Modifiers

According to HCFAs 2001 National Physician Fee Schedule, procedures that may result in a post-tonsillar bleed, such as tonsillectomies, have 90-day global periods (most private payers have a 30- to 45-day global for these procedures). Any procedure performed during this global period is not payable separately unless it is appended with a modifier that exempts it from global surgery guidelines. Furthermore, 42960, 42961 and 42962 are bundled to tonsillectomy codes 42825 and 42826 in the national Correct Coding Initiative (but not to UPPP, 42145).

If, for example, the patient has a severe enough post-tonsillar bleed to warrant a return to the operating room, code 42962 should be appended with modifier -78 (return to the operating room for a related procedure during the postoperative period) to inform the carrier that surgical control of the hemorrhage is separately payable.

Some coding specialists complain that appending modifier -78 should not be necessary when billing 42962 because the code already describes secondary surgical intervention (i.e., a return to the operating room [OR]) and use of the modifier limits payment to the intra-operative portion of the procedure in the HCFA fee schedule (70 percent). Without the modifier, however, the carriers software will automatically include 42962 in the primary procedures global package and deny payment.

No modifier specifically describes the circumstances described by codes 42960 and 42961 (i.e., there is no modifier for complications that dont involve a return to the OR). Presumably, the AMA has not created such a modifier intentionally, and reasons that complications treated in the office or the ED are part of the surgical package of the original procedure and should not be separately billed.

HCFA shares this view and clearly states in its global surgery guidelines (found in section 4821 of the Medicare Carriers Manual) that global periods specifically include complications defined as all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room following surgery.

If the guidelines apply to 42960 and 42961 (and, other than the fact that these codes exist and describe the treatment of a specific complication, there is no reason to believe they shouldnt), these codes should never be billed to Medicare when they are performed by the same physician who performed the original procedure. Local Medicare carriers may differ in their interpretation of the global surgery guidelines and in their payment policies for 42960 and 42961, however, and may accept the codes if appended with modifier -78 or if the service is provided on the same day as the primary procedure modifier -59 (distinct procedural service). Coders should check with their specific carrier for instructions on how to deal with such claims.

Note: Regardless of the payers policy, reimbursement for codes 42960-42962 is problematic only if the same otolaryngologist performed the original procedure. If another physician performed it, the codes should be billed without modifiers, and payment should be forthcoming.

Gain Reimbursement from Private Payers

Children and adults under age 65 (i.e., non-Medicare patients) make up the majority of tonsillectomy patients, and most private payers consider complications such as post-tonsillar bleeds to be an unrelated problem. In many cases payment for 42960 and 42961 can be received by appending modifier -79 (unrelated procedure or service by the same physician during the postoperative period).

The CPT descriptor for modifier -79 doesnt say a word about complications, notes Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. The descriptor only specifies that the problem must be unrelated. Because Medicares global surgery guidelines state that complications not requiring a trip to the OR are part of the surgical package [i.e., related], modifier -79 cant be used for Medicare patients. But it can be used with private carriers who dont follow this guideline and consider most complications unrelated.

Not all private payers that reimburse 42960 and 42961 will accept modifier -79, however. For example, says Ann Hughes, CPC, a practice coder with Mid-Vermont ENT, a physician office in Rutland, Vt., Some insurance companies we deal with tell us to use modifier -58 [staged or related procedure or service by the same physician during the postoperative period]. But most of the time we dont put a modifier on either code, and we always get reimbursed.

Because the original procedure had a global period, however, other carriers may deny the procedure unless a modifier is attached and some, like Medicare, may not pay at all. Therefore, otolaryngologists should try to obtain a pre-determination about how such claims should be filed and what payment they can expect, says Cheryl Odquist, CPC, an independent otolaryngology coding and reimbursement specialist in San Diego.

Carriers may not follow HCFA guidelines, or may flip-flop, so you have to clarify their policies ahead of time, Odquist advises. She recommends obtaining a pre-determination on hemorrhage control at the same time the original procedure is precertified. That way, youll know if the carrier will pay for the procedure and which, if any, modifiers to use.