Otolaryngology Coding Alert

Question: The otolaryngologist performed a tonsillectomy on a 14-year-old patient. The patient had profuse bleeding, and the surgeon had to return to the operating room later the same day to control the bleed. Is the return to OR billable on the same day?

Colorado Subscriber

Answer: The surgery day counts as part of the postoperative period. "Services provided on the day of surgery but before the surgery are considered preoperative by CMS, while services furnished on the same day but after the surgery are considered postoperative," writes Deborah Grider, CPC-EMS, CPC-H, CPC-P, CCS-P, in Coding With Modifiers: A Guide to Correct CPT and HCPCS Level II Modifier Usage.

Impact: The tonsillectomy's (42825, Tonsillectomy, primary or secondary; younger than age 12) 90-day global period begins on the surgery day. You may bill the bleed control requiring a return trip to the OR. To indicate that the hemorrhaging was related to the tonsillectomy and required OR use, report the bleed control (42962, Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; with secondary surgical intervention) with modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).