Otolaryngology Coding Alert

Question: Our otolaryngologist performs tonsillectomies and adenoidectomies (T&As) as an outpatient service. After the surgery, the physician admits the patient to observation and discharges him or her later that day or the following morning. Should I separately report the admit and discharge?


Mississippi Subscriber


Answer: No, you shouldn't report an admission and discharge in these cases. Even though the otolaryngologist elects to perform T&As on an outpatient basis, he must still monitor the patient for postoperative bleeding.

The University of Tennessee Department of Otolaryngology suggests that surgeons performing outpatient T&As should not discharge patients "until the immediate postoperative bleeding period has passed (In the case of tonsillectomy this may be six to eight hours) and they demonstrate an adequate oral intake." Thus, your otolaryngologist's practice of routinely admitting patients to observation for several hours or overnight is part of the normal postoperative care that CPT includes in the surgical package. So you shouldn't report a same-day admit and discharge (99234-99236) or different day admission (99218-99220) and discharge (99238-99239).

If, however, the patient developed a surgical complication, you could bill the admission and discharge. For the nonroutine care, bill the appropriate E/M depending on the payer and the care.

Example: Following a T&A, a patient develops an abscess. The otolaryngologist readmits the patient to the hospital and initiates IV antibiotic treatment. He discharges the patient the next day.

You could bill third party payers with the appropriate admission code (such as 99221, Initial hospital care, per day, for the evaluation and management of a patient ...) and discharge code (for instance 99238, Hospital discharge day management; 30 minutes or less). To indicate that the payer does not include the service in the initial surgery's global fee, append the E/M service with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period). Make sure to link the hospital code to the abscess diagnosis (475, Peritonsillar abscess), not to tonsillitis (such as 474.00, Chronic condition of tonsils and adenoids; chronic tonsillitis).

Medicare alert: Medicare, however, will only pay for surgical complications that require a return to the operating room (OR). So you shouldn't bill the above scenario to Medicare or to payers that follow CMS rules.

But if the otolaryngologist had to drain the abscess (for example, 42700, Incision and drainage abscess; peritonsillar), you should report the procedure to Medicare. To indicate the complication required return to the OR during the postoperative period, append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 42700.

Reminder: Many T&A patients are children who don't qualify for Medicare. So you may in fact be able to charge their insurers for non-OR complications.