AN2114
Guru
I just want to make sure I'm using the correct cpt code because I have read a few different things so I am a little confused which code to use. From my understanding code 42960 is for a post tonsillectomy bleed that can be fixed in the office. Code 42961 is when they can't fix it in the office so they send the patient to the hospital. And 42962 is when they take the patient to the OR. But I also read that if cauterization is done the code is 42960 and if suture ligation of bleeding vessels is done that is code 42962. So that is where I am confused and want to make sure I'm coding this right. Below is the op report.
Patient was taken to surgery induced with general anesthesia and intubated. Shoulder roll was placed to provide neck extension. Patient was then properly prepped and draped. McIvor mouth gag was inserted into the mouth and patient was suspended from the Mayo stand. Attention was turned to the left fossa. A large clot was suctioned off revealing a bleeding vessel in the midpole region. This was cauterized using suction cautery. Once hemostasis was achieved the mouth gag was released and the patient was valsalva'd to 35 mmHg twice. The mouth gag was then resuspended and any areas of oozing were cauterized. The stomach was then suctioned and Floseal was placed in bilateral tonsillar foassas. Case was completed. All instrumentation was removed and patient was sent to recovery in satisfactory condition.
Also, the physician that did the original tonsillectomy is from a different office. But I would still use modifier 78 right?
Patient was taken to surgery induced with general anesthesia and intubated. Shoulder roll was placed to provide neck extension. Patient was then properly prepped and draped. McIvor mouth gag was inserted into the mouth and patient was suspended from the Mayo stand. Attention was turned to the left fossa. A large clot was suctioned off revealing a bleeding vessel in the midpole region. This was cauterized using suction cautery. Once hemostasis was achieved the mouth gag was released and the patient was valsalva'd to 35 mmHg twice. The mouth gag was then resuspended and any areas of oozing were cauterized. The stomach was then suctioned and Floseal was placed in bilateral tonsillar foassas. Case was completed. All instrumentation was removed and patient was sent to recovery in satisfactory condition.
Also, the physician that did the original tonsillectomy is from a different office. But I would still use modifier 78 right?