Otolaryngology Coding Alert

Question: Patient had outpatient surgery:

·         42145 for the UPP,

·         42826 for the tonsils, and

·         31600 for the trach (added due to breathing difficulty).

The patient was then transferred to another hospital the same day due to respiratory problems. The second hospital required an inpatient admission, and the patient seen daily for three days (99232).

How do I properly code the same day admission to the second hospital? Would the daily visits need modifiers? Can I also charge for hospital-discharge?

Additional problem: The patient was taken back to OR at the first hospital the day after his inpatient discharge for a trach change. Is the correct coding for this surgery 31502 with modifier 78?

New Jersey Subscriber

Answer: Moving the patient to a different hospital does not invalidate the global period from the surgery. Code 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) has a global period of 90 days. So does 42826 (Tonsillectomy, primary or secondary; age 12 or over). That means you should include any related E/M services provided.

If the documentation supports that the admission and the rounds are only related to the respiratory problem and not related to the surgeries performed, you could bill them with 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient … ) with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period). 

If part of the E/M services attended to post op care, you need to carve that out and only code the part related to the respiratory problem with modifier 24, so instead of using 99232, the unrelated care might only support a 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient … ).

Also of note, the Correct Coding Initiative (CCI) bundles 42826 into 42145, and you cannot unbundle it. If the tonsillectomy added sufficient complexity to the surgery to justify the increased complexity modifier (22, Increased procedural services), you should use that. But the documentation has to demonstrate that the complexity was increased by at least more than 25% to use modifier 22.

If the trach change was before the fistula track was established (it sounds like it was since it usually takes about a week for the fistula track to establish), based on the timing, you can use 31502 (Tracheotomy tube change prior to establishment of fistula tract). If the physician is changing the trach tube due to complications, you would use 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), but if you were changing it because you are not getting your desired outcome, you would use staged procedure modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period).