Medicare Compliance & Reimbursement

Hint: Don’t forget to review NCCI policies.

During a surgical procedure or in the midst of a postoperative complication, physicians may have to control a patient’s bleeding. The variety of scenarios are endless as are the wide array of code choices, which can pose a challenge and lead to denials.

Whether you’re a novice or an ace at coding bleeding scenarios, consider reviewing these three handy steps before you collate your report.

Step 1: Recognize Bleeding Control Methods

The operative report or the post-surgical visit report might mention a variety of terms that indicate the surgeon has used a method to control bleeding associated with surgery. Make sure you’re familiar with the following terms so you won’t miss the provider’s documentation for control of bleeding:

• Cauterize: Burn tissue to seal and stop bleeding.
• Clip or Clamp: Device used to compress and close off a bleeding vessel, such as a hemostat or endoclip.
• Electrocautery: Use of high frequency electrical current, either monopolar or bipolar, to cauterize tissue.
• Hemostasis: Control of bleeding, such as from incisions and suture lines.
• Infrared coagulation: Use of infrared light (a type of electromagnetic radiation) to cause blood clotting.
• Laser ablation: Use of heat produced by focused light energy (laser) to cauterize tissue.
• Plasma coagulation: Use of ionized gas (such as argon) to cause blood clotting.
• Radiofrequency ablation: Use of heat produced by focused radio waves (a type of electromagnetic radiation) to cauterize tissue.
• Staple: A U-shaped fastener to close wounds, often instead of sutures.
• Suture ligation: Encircling a vessel with thread, wire, band, or similar material to compress and close off a bleeding vessel.

Step 2: Scour CPT^® for Site-Specific Codes

Physicians might use one of myriad codes from various CPT^® surgery chapters that describe bleeding control, such as the following:

• 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage)
• 32654 (Thoracoscopy, surgical; with control of traumatic hemorrhage)
• 42960 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple)
• 42961 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring hospitalization)
• 42962 (Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical intervention)
• 42970 (Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/ or cautery)
• 42971 (Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization)
• 42972 (Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); with secondary surgical intervention)
• 43227 (Esophagoscopy, flexible, transoral; with control of bleeding, any method)
• 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method)
• 44366 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
• 44378 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
• 44391 (Colonoscopy through stoma; with control of bleeding, any method)
• 45317 (Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator))
• 45334 (Sigmoidoscopy, flexible; with control of bleeding, any method)
• 45382 (Colonoscopy, flexible; with control of bleeding, any method)
• 46614 (Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator))

You can see from this code list that CPT^® provides specific codes for surgical bleeding control based on the surgical procedure/site, the control method (in some cases), and possibly whether the bleeding control is during the initial surgery or during the post-op period.

Caveat: “If the surgeon controls bleeding while performing an endoscopic procedure such as removing a biopsy or polyp, you should not additionally report the code for bleeding control,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

Here’s why: CPT^® guidance states “when bleeding occurs as the result of an endoscopic procedure, control of bleeding is not reported separately during the same operative session.” Also, National Correct Coding Initiative (NCCI) edits bundle the bleeding control codes with other procedures in the same code family.

However: If the surgeon performs a procedure such as a biopsy or polypectomy and documents that the control of bleeding at the site is extensive, modifier 22 (Increased procedural services) might apply, according to Joy.

Step 3: Study Some Clinical Examples to Hone Your Skills

Look at the following examples to see how to apply the bleeding control codes.

Example 1: The physician performs an esophagogastroduodenoscopy (EGD) and documents a 2 mm bleeding polypoid arteriovenous malformation (AVM) in the proximal jejunum. The surgeon controls the bleeding by ablation with bipolar circumactive probe (BICAP) cautery and endoclip application.

Solution 1: The doctor documents using two methods to control bleeding of the AVM: electrocautery and a clip. Report this as one unit of 43255.

More: Remember that if the physician documented additional work, such as removing the polypoid AVM by snare technique, you should report just 43251 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) and not additionally report 43255. However, if the provider removed a separate lesion at a different site during the same endoscopy, you should report both codes using a modifier such as 59 (Distinct procedural service).

Example 2: A 65-year-old patient undergoes primary tonsillectomy and adenoidectomy. Three days following the procedure, the physician treats the patient in the office for post-operative bleeding in the nose and throat area.

Solution 2: Report the original tonsillectomy/adenoidectomy as 42821 (Tonsillectomy and adenoidectomy; age 12 or over). For the control of bleeding three days later, separately report 42970. You can separately report the bleeding control even though it’s during the post-op period because CPT^® surgery guidelines state, “Follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported.”

Hint: Report the diagnosis for the visit as J95.830 (Postprocedural hemorrhage of a respiratory system organ …). “Append modifier 79 (Unrelated procedure or service by the same physician … during the postoperative period) as the diagnosis would be unrelated to the original surgery,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Caution: Medicare has a different rule, in this circumstance. According to the NCCI Policy Manual, Chapter 1, section C, subsection 14, “control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable 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].”