Otolaryngology Coding Alert

Question: An otolaryngologist removed a patient’s palate lesion (42120) on 3/24/2013. The patient went to the emergency room for profuse bleeding on 3/29/2013. The ER physician sent the patient to the otolaryngologist’s office. The bleeding had stopped. The otolaryngologist saw the patient, cauterized the wound’s edges, took off a clot and suctioned around the edges. How should I code for the service, or is the treatment part of the global and unbillable?

Illinois Subscriber

Answer: You should include the non-bleeding episode as part of the palate resection’s (42120, Resection of palate or extensive resection of lesion) 90-day global period. The wound edge cautery, clot removal and suctioning are part of the postoperative care.

On the other hand, if the patient’s condition required more work and the patient is not a part B Medicare patient, you could bill for the procedure. AMA CPT^® states that complications and exacerbations are not part of the global service.  But CMS states that the global package does include treatment for complications unless the complication requires a return trip to the operating room.  Suppose the non-Medicare patient arrives at your office bleeding profusely. In this case, you should report the palate hemorrhage control appended with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to indicate that the procedure is unrelated to 42120’s global period.

For palate hemorrhage control, you can use 42960 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; simple). The palate is part of the oropharynx region, which includes the region between the soft palate and the upper edge of the epiglottis.