Otolaryngology Coding Alert

Question: Our patient had a tonsillectomy. Four days later, she came to the ER with a postoperative bleed that required a trip to the operating room to control; she was then admitted overnight. Three days later, the patient arrived in the ER and was seen for another bleed, which was subsequently controlled in the operating room. The doctor again admitted the patient overnight. I should report 42962-78 for both dates. May we code for the ER visits? How about the admission and discharge also?

Utah Subscriber

Answer: The answer depends on whether the patient is a Medicare patient or has insurance that states in writing that they follow Medicare rules for postoperative complication care.

Medicare states it does not pay for postoperative complications unless they require a return to the operating room. Therefore, any care for complications done in the office, bedside, or in the emergency room during the global period for the original procedure are not a billable service to Medicare.

This means that the ER visit for the postoperative bleed four days after the surgery and then three days later would not be coded or billable to Medicare or to any payer that follows Medicares policy. The admissions and discharges would be part of the global of the bleed control, 42962 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; with secondary surgical intervention), and would not be subsequently billable.

The AMA states in the preamble to the surgery section to CPT that the global does not include care for postoperative complications and that this care for complications and exacerbations should be separately coded and billed. So, if the patient does not have Medicare or a payer that follows Medicares rules, you can code and bill the ER E/M services. They would be coded as 9921x-24.

Append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) and link to the diagnosis for the postoperative bleed.