Otolaryngology Coding Alert

Answer: CPT contains three codes for post-tonsillectomy hemorrhaging. If the physician controls the bleeding in the office with cautery or packing, 42960 (Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; simple) describes the service. Code 42961 ( complicated, requiring hospitalization) reflects hemorrhaging that requires more extensive treatment in the emergency room (ER) and/or hospitalization. When the physician must use surgical intervention to stop the bleeding, 42962 ( with secondary surgical intervention) describes the procedure.

In your case, the otolaryngologist first treated the patient in the ER (42961), which is a billable procedure to private payers only. Medicare considers postoperative tonsillectomy care that does not require a return to the operating room to be included in the 90-day global period for tonsillectomy (42825, Tonsillectomy, primary or secondary; under age 12; and 42826 ... age 12 or older).

Medicare and commercial insurers cover your otolaryngologist's second procedure (42962). If the physician controls the bleeding during the tonsillectomy's 90-day global period, append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to break the payer's global period for the tonsillectomy (42825-42826).

For non-Medicare payers, submit these procedures on different claims due to separate places of service.To indicate that the ER procedure (42961) is a distinct procedural service from the surgical procedure (42962), you will also have to append modifier -59 (Distinct procedural service) to 42961. Documentation should show that your physician performed both procedures on the same day but at separate times and settings.