Provider-Insurer Communication Crucial When Billing for Post-tonsillar Bleed Control
Published on Thu Feb 01, 2001
Post-tonsillar bleeds are controlled during the global period of another procedure. This can make billing such procedures difficult, because no comprehensive or authoritative guidelines satisfy all payers. Although most private carriers pay separately for control of post-tonsillar bleeds even if a trip to the operating room is not required, Medicares global surgery guidelines include such complications. Local Medicare carriers vary in their policies, however, as do private insurers, which makes provider-insurer communication vital to gaining reimbursement for these procedures.
Complexity Determines Proper Coding
Post-tonsillar bleeds, or oropharyngeal hemorrhages, usually occur as a complication of surgery, most frequently tonsillectomy, but also uvulopalatopharyngoplasty (UPPP) and other procedures. The bleed may be either primary occurring within the first 24 hours after surgery or secondary beginning days after the primary procedure.
CPT includes three codes for control of a post-tonsillar bleed, each describing progressive levels of complexity:
42960 control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; simple
42961 complicated, requiring hospitalization and
42962 with secondary surgical intervention.
If, for example, a patient who is six days post-tonsillectomy bleeds from the right tonsil fossa and the otolaryngologist sees the patient in the office (or the emergency department [ED]) to control the bleeding, the appropriate code is 42960.
Code 42961 describes a more complicated encounter. For example, there may be a concern about blood loss if attempts to stop the bleeding in a hypotensive patient have failed, and the otolaryngologist may admit the patient to the hospital to control the problem.
Code 42962 correctly describes a situation in which the otolaryngologists attempts to control the bleeding remain unsuccessful, and the patient must return to the operating room for further surgery.
Note: CPT includes similar codes (42970, control of nasopharyngeal hemorrhage, primary or secondary [e.g., postadenoidectomy]; simple, with posterior nasal packs, with or without anterior packs and/or cauterization; 42971, complicated, requiring hospitalization; and 42972, with secondary surgical intervention) for the control of bleeding that may be performed after an adenoidectomy. Such procedures are performed less frequently than those following a tonsillectomy or UPPP.
Understand Billing Issues and Modifiers
According to HCFAs 2001 National Physician Fee Schedule, procedures that may result in a post-tonsillar bleed, such as tonsillectomies, have 90-day global periods (most private payers have a 30- to 45-day global for these procedures). Any procedure performed during this global period is not payable separately unless it is appended with a modifier that exempts it from global surgery guidelines. Furthermore, 42960, 42961 and 42962 are bundled to tonsillectomy codes 42825 and 42826 in the national Correct Coding Initiative (but not to UPPP, 42145).
If, for example, the patient has a severe enough post-tonsillar bleed to warrant a return to the operating room, code 42962 should be appended with [...]
