Otolaryngology Coding Alert

Question: Where can I find the global postoperative period for different procedures, such as a tonsillectomy?

Delaware Subscriber

Answer: Many private payers follow Medicare's postoperative surgical schedule. You can download Medicare's 2004 National Physician Fee Schedule Relative Value File from www.cms.hhs.gov/providers/pufdownload/default.asp#pfsrelative. When you open file PPRRVU04.xls, you can enter a CPT code in the finder window and scroll across to the global-days field. The number in this column is how many postoperative days Medicare includes in the procedure's global surgical period. For instance, 42826 (Tonsillectomy, primary or secondary; age 12 or over) contains 90 global days.

You will have to contact individual payers for their fee schedules. Although many adopt Medicare's guidelines, some insurers' postoperative periods for specific procedures differ from CMS'.

Some private payers' surgical periods may work to your advantage. For example, an otolaryngologist controls a post-tonsillectomy patient's hemorrhaging in the office. Some third-party payers consider postoperative bleeding unrelated to the tonsillectomy and reimburse for 42960 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; simple) and 42961 (... complicated, requiring hospitalization). For these payers, you should append modifier -59 (Distinct procedural service) to 42960 or 42961 to indicate a separate operative session on the same day of the original procedure. If the bleeding occurs on a different day, use modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) for reimbursement during the post-op period.

Medicare, however, will not reimburse for oropharyngeal control that doesn't require a return to the operating room (modifier -78, Return to the operating room for a related procedure during the postoperative period). So, you should bill Medicare for 42962-78 (... with secondary surgical intervention) only, not 42960-42961.

-- Answers to You Be the Coder and Reader Questions provided by Andrew Borden, CCS-P, CPC, CMA, department of otolaryngology and communication sciences reimbursement manager at Medical College of Wisconsin in Milwaukee; Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.; and Gregory L. Schnitzer, RN, CCS, CCS-P, CPC, CPC-H, RCC, CHC, manager of coding compliance and quality assurance for CodeRyte in Bethesda, Md.