Otolaryngology Coding Alert

Depending on the severity of bleeding the otolaryngologist treats the patient in the:

1. office
2. hospital
3. or the operating room (OR).

By knowing the levels of bleeding and typical treatments in each location you can correctly choose the appropriate post-tonsillar hemorrhage code. All postoperative complications are included in the global period of the original procedure. Therefore modifiers will apply to these codes as discussed later.

"Bleeding may be brief and self-limited or stop after ice-water gargles " Wanamaker says. "These symptoms require only office follow-up which is generally included in the global as postoperative care. More severe bleeding may require an office visit for packing or cautery coded as 42960 site of visit in-office [11]."

For example suppose a healthy post-tonsillectomy adult has severe bleeding two days after surgery and presents to the otolaryngologist's office. The physician discovers the hemorrhaging is coming from the right fossae. He controls the bleeding by simple cautery.

"42960 is the appropriate code to use if the patient is treated in the office with simple cautery " says Beth Thomsen CPC Associated Physicians of MCO Inc. Toledo Ohio.

"Active persistent bleeding may require control in the emergency room where sedation topical or local anesthetic pain control fluid replacement and hematologic studies may be performed " Wanamaker explains. "The patient may either have observation status or be admitted for observation/treatment."

"42961 is indicated if the patient requires additional treatment or observation in an outpatient inpatient-bedside hospital setting or emergency room " Thomsen says.

For instance a 27-year-old male has excessive persistent bleeding. The physician is unable to treat the patient in the office and sends him to the emergency room. In the ER the otolaryngologist applies tannic acid to the affected site and the bleeding subsides. Assign 42961.

Because the hemorrhaging was extensive enough to require treatment in the emergency room you should report complex post-tonsillectomy bleeding code 42961.

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

For instance a 15-year-old-female presents to her otolaryngologist following a tonsillectomy. She has a rapid pulse rate and is coughing fresh blood. The physician applies epinephrine mixed with Xylocaine to the oropharynx region and the bleeding subsides. Due to the patient's extensive blood loss and concern that the bleeding may recur he admits her to observation. After 24 hours the patient is released. Report complex postop tonsillectomy hemorrhaging (42961).

The severity of the symptoms and the underlying concerns required hospital observation. Therefore the doctor has met the conditions for 42961 (hospitalization).

"42962 is for use when the patient must return to surgery " Thomsen says. In cases of severe or persistent bleeding usually an arterial bleeder the patient requires control in the operating room with electrocautery or ligation Wanamaker states.

Many patients especially children cannot tolerate in-office bleed-control methods adds John Fink MD. "You usually have to go to the operating room for general anesthesia."

For instance a 4-year-old boy who has post-tonsillar bleeding presents to an otolaryngologist's office. He will not hold still for the otolaryngologist to attempt to stop the hemorrhaging. Treatment necessitates general anesthesia and surgical intervention and therefore a trip to the operating room. Assign 42962.

Consider how often you will use each code. Local measures are sufficient to treat three-quarters of patients who require extensive treatment Wanamaker estimates. "A small number of patients require control in the operating room " he says. "The typical general ENT surgeon will probably only have one or two cases per year requiring operative control based on our hospital data."

That suggests you will usually report the lower-valued codes 42960 (4.63 relative value units [RVUs]) or 42961 (11.29 RVUs). You will rarely assign 42962 which consists of 14 RVUs. Most of the time an office or emergency room visit or hospitalization will suffice and you will report a simple (42960) or complex (42961) post-tonsillar hemorrhage code. In the other cases severe bleeding will occur that requires a return to the operating room and warrants a second surgical procedure code (42962).

The 2002 Medicare Fee Data Base factors the cost of postoperative tonsillectomy care into tonsillectomy codes 42825 and 42826. All related postoperative care for 90 days after surgery is included in the cost of the original surgical operation and cannot be reported separately including "normal" postoperative complications not requiring a trip to the operating room. This is a Medicare rule not a CPT rule.

"Physicians may hesitate to bill for these codes [42960-42962] because they assume these treatments are included in the global package " Thomsen says. When postoperative care requires a return to the operating room modifier -78 (Return to the operating room for a related procedure during the postoperative period) is required to make this procedure payable during the payer's global period for 42962.

For instance a 68-year-old female has severe hemorrhaging. The otolaryngologist is unable to control the bleeding and treats the patient in the operating room. The physician should report 42962-78.

The hemorrhaging required surgical intervention so 42962 is warranted. Modifier -78 breaks the carrier's global period edit for 42826 (Tonsillectomy primary or secondary; age 12 or older).

However this modifier applies only to procedures that require surgical intervention. Therefore only post-tonsillectomy code 42962 qualifies for Medicare reimbursement.

Because Medicare does not pay for complications treated outside of the operating room you do not bill 42962 or 42961. (Medicare considers it part of the global.) However if another doctor outside of the practice performs the procedure he or she may bill the appropriate code.

Many tonsillectomy patients are children or adults who do not qualify for Medicare coverage. CPT does not consider complications part of the global package and thus individual carrier guidelines vary on their interpretations of Medicare's global package. Many private payers consider postoperative bleeding unrelated to the tonsillectomy and reimburse for 42960 and 42961.

If the postoperative bleed happens on the same day as the tonsillectomy 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 postop period.