tboersma
Contributor
Re: Post-tonsillectomy Hemorrhage CPT Assignment
42960 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple)
OR
42962 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical intervention)
I'd like to get some other opinions on code selection, please. The procedure description matches 42960, however, the patient had to be taken back to the OR and put under general anesthesia, so is more involved than the "simple" procedure.
Would you assign 42960, 42962 or 42960-22? Thank you!
Per the OP report:
31 year old white male who developed persistent bleeding after coughing on his way home from the hospital after tonsillectomy today. IV and topical TXA given on his return to the hospital with slowing, but not control of the bleeding. He is now being taken back to the OR for control of the hemorrhage and intubation and lavage of his stomach to remove swallowed blood and food before awakening.
After obtaining informed consent from the patient, they were taken to the operating room and placed in a supine position. A general endotracheal anesthetic was administered by the nurse anesthetist. A rapid induction sequence was performed.
A McIvor mouth gag was inserted transorally and suspended from a Mayo stand over the patient's chest.
Blood clots were removed and the oropharynx was irrigated with sterile saline until clear.
Two site of bleeding were identified in the right tonsil fossa and cauterized with a suction bovey. The right tonsil fossa was then packed with TXA soaked tonsil sponges.
There was no bleeding from the left tonsil fossa
An orogastric tube was then passed down into the stomach and the stomach contents were removed with suction and lavage with 1500 ml of saline. The tonsil packs were then removed and fossa bed was suctioned to see if any more loose vessels could be found. It remained dry
The mouth gag was removed and the patient was awakened, extubated, and taken to the PACU in stable condition.
42960 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple)
OR
42962 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical intervention)
I'd like to get some other opinions on code selection, please. The procedure description matches 42960, however, the patient had to be taken back to the OR and put under general anesthesia, so is more involved than the "simple" procedure.
Would you assign 42960, 42962 or 42960-22? Thank you!
Per the OP report:
31 year old white male who developed persistent bleeding after coughing on his way home from the hospital after tonsillectomy today. IV and topical TXA given on his return to the hospital with slowing, but not control of the bleeding. He is now being taken back to the OR for control of the hemorrhage and intubation and lavage of his stomach to remove swallowed blood and food before awakening.
After obtaining informed consent from the patient, they were taken to the operating room and placed in a supine position. A general endotracheal anesthetic was administered by the nurse anesthetist. A rapid induction sequence was performed.
A McIvor mouth gag was inserted transorally and suspended from a Mayo stand over the patient's chest.
Blood clots were removed and the oropharynx was irrigated with sterile saline until clear.
Two site of bleeding were identified in the right tonsil fossa and cauterized with a suction bovey. The right tonsil fossa was then packed with TXA soaked tonsil sponges.
There was no bleeding from the left tonsil fossa
An orogastric tube was then passed down into the stomach and the stomach contents were removed with suction and lavage with 1500 ml of saline. The tonsil packs were then removed and fossa bed was suctioned to see if any more loose vessels could be found. It remained dry
The mouth gag was removed and the patient was awakened, extubated, and taken to the PACU in stable condition.