Otolaryngology Coding Alert

Making the proper coding distinctions is only half the battle.

If you code a given surgery with enough frequency, you’ll typically have no problem handling each and every variation of an operative report that comes your way. Getting into a coder’s groove can be easy until you come across one of those seldom-seen scenarios that grinds you to a screeching stop.

Tonsillectomy and adenoidectomy procedures fall into the category of the former, but you’ve got to know exactly how to handle those lesser seen follow-up scenarios in which the surgery results in an oropharyngeal hemorrhage complication.

Avoid any future snags in your coding process by getting all the pertinent details on post-procedural oropharyngeal hemorrhage coding.

See What Constitutes Simple Versus Complicated

In outlining the differences between codes 42960 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple) and 42961 (… complicated, requiring hospitalization), you don’t need any further information outside of the code descriptions to distinguish between a simple and complicated control of an oropharyngeal hemorrhage. If the treatment that’s needed involves hospitalization, then you should consider the surgery complicated, by default.

When it comes to hospitalization, a patient may either be admitted for observation or be taken directly to the emergency room (ER) or operating room (OR). If a form of treatment, such as cauterization, is needed to control the hemorrhage, the patient may be given general anesthesia and be subsequently intubated.

As for the distinction between primary and secondary oropharyngeal hemorrhage, you’ll want to look no further than the time elapsed from the underlying surgery. If the hemorrhage occurs within 24 hours of the original procedure, the hemorrhage is considered a primary oropharyngeal hemorrhage. If the hemorrhage occurs from a period of 24 hours to two weeks following the original procedure, you’ll consider the hemorrhage a secondary complication.

Discern Between 42961, 42962

On the surface, codes 42961 and 42962 (…with secondary surgical intervention) share the majority of the same characteristics. You should report both when the patient returns to the OR following a tonsillectomy and/or adenoidectomy that results in hemorrhaging of the oropharyngeal tract. However, understanding what constitutes “secondary surgical intervention” is paramount in complying with the coding guidelines.

The main source of confusion comes from the fact that both codes technically involve some form of surgical intervention — it’s up to you to evaluate the operative report to determine whether the intervention goes as far as to warrant the use of code 42962. This means breaking down what surgical techniques are typically applied to each respective code.

When reporting 42961, you’ll want to look out for more “simple” methods of hemorrhagic control such as clot evacuation, cauterization (electrocautery), and the application of sponges or vasoconstrictor solutions. The most common surgical technique that warrants the use of code 42962 is suture ligation of the bleeding vessels. You’ll want to use extreme caution in making sure you understand what surgical circumstances warrant the use of 42962 over 42961. If the operative note only makes a reference to the suctioning off of a clot and subsequent cauterization of the vessel, then you’ve only got enough documentation to support 42961.

Keep These Medicare Reimbursement, Modifier Notes In Mind

Getting the coding fundamentals down pat won’t necessarily ensure that the claim gets paid, though. Reimbursement for a control of an oropharyngeal hemorrhage will depend on some important variables — with the most notable of which being the payer. The code description in 42960 notes that it should be used for intervention of both primary and secondary oropharyngeal hemorrhages. However, Medicare is known to deny payments for secondary (e.g., post-tonsillectomy) oropharyngeal hemorrhages treated in an office setting.

Furthermore, you’ll want to append the appropriate modifier when using these codes since they occur during the 90-day global period of the tonsillectomy or tonsillectomy and adenoidectomy surgeries. “In order to know if the services are reimbursable, the definition of the global period and treatment of complications must be understood,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey.

“Medicare Part B, for instance, does not pay for complications unless it requires a return to the operating room. In fact, you may only bill a bleed that requires a return to the operating room to the Medicare Carrier for Part B patients. As a result, 42960 is not a billable service,” explains Cobuzzi.

When the surgeon performs code 42961 in the operating room, you may submit it to Medicare Part B with modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period). Similarly, 42962 takes place in the operating room and is therefore always billed to Medicare Part B with modifier 78.

Note: While each commercial payer varies in its policy, you should expect most payers to reimburse for 42960 performed within the global period of codes such as 42821 (Tonsillectomy and adenoidectomy; age 12 or over) and 42826 (Tonsillectomy, primary or secondary; age 12 or over).