Otolaryngology Coding Alert

Question: A patient had a tonsillectomy and adenoid removal. She was hospitalized for observation but no secondary surgical intervention took place. Is it appropriate to bill 42961, or is it considered part of the global period? 

Louisiana Subscriber 

Answer: Because the patient’s hemorrhaging was extensive enough to require treatment in the hospital, you should report code 42961 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; complicated, requiring hospitalization).  

Contributing factors such as dehydration or a need for fluid replacement in any patient who has bleeding may warrant observation or hospitalization even after bleeding subsides. 

Caveat: Consider the payer before submitting 42961. Medicare does not pay for complications treated outside of the operating room because they view it as part of the global service. Therefore, you would not bill 42961 or 42962 (…with secondary surgical intervention) to Medicare. Many private payers follow the AMA definition of global periods and post-operative care, which states that any complications and/or exacerbations are separately coded and billed. Therefore, caring for a postoperative bleed is appropriate and they should reimburse for 42960 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; simple) and 42961. You would append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to 42961and use the diagnosis of post-operative haemorrhage, 998.11 (Do not use the reason for the tonsil surgery with 42961).