Wiki 42960 or 42961 or 42962 for cautery of palate

wynonna

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Surgery done in OR under endotracheal anesthesia. Patient taken to OR from ER and Discharged same day from Recovery same day. So, the patient was not admitted but was in the OR with ENT surgeon to stop bleeding from an excision of hard palate in mouth (done at a prior time at another facility.)
 
I think you need to look under the section "Palate and Uvula" to start with and possible use an Unlisted Procedure code. Also you'll need a modifier for unplanned procedure.
 
Nope you're still in the wrong body part section. That is listed under the subtitle (in red letters) for Pharynx, Adenoid, and Tonsils. The mention of "Hard Palate" should lead your search.
In the index, follow this trail (stick with me, it's all a process!)
Palate - Repair - listed under this is Cleft, Laceration, Vomer, and the Unlisted code. There is no code listed for "hemorrhage control" so head for the first listing so you can read through the options. (code 42180; pg 306)

With cautery of excision site as the method used, there is no exact code in this section describing this. So you're left with the unlisted code under "Other Procedures"

I even looked for something for cautery of surgical wound on mucous membrane of palate or mouth and found nothing I would rather use than the "other".

Another thing to consider: although this was a different surgeon, were both surgeons in the same physician's group? If yes, this could be considered part of the global care fee for this procedure and the care rendered bundled with the surgical fee.

I am not an experienced coder but it is very important you know what body part you are reading about to narrow down where the work is being done and let that guide you to the correct coding section. It's like following a map - one wrong turn and you find yourself in Timbuktoo! Keep smiling!
 
Thank you kindly for your help! I will query my manager or the provider to find correct CPT, whether it is 42180 or unlisted. The initial procedure was done by oral surgeon at a different office, and we are ENT, so global doesn't apply and we can bill for procedure.
Keep smiling yourself. :)
 
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