RF Palatoplasty w/emergency tonsillectomy


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Doctor did a radiofrequency palatoplasty which resulted in profuse bleeding from the puncture site. An emergency tonsillectomy had to be done to control the bleeding. How would this be coded?
Hi Coder Guy~ I just ran into this myself when our patient's stomach was accidentally torn due to take down of adhesions. You can only bill for the procedure you did not the procedure you had to do to correct the "surgical misadventure". To bill this would be charging the patient for a mistake the surgeon unintentionally made but had to be repaired.

Here is what CCI states:

"CCI Manual Chapter 01
10. A number of CPT codes describe services necessary to address the treatment of complications of the primary procedure (e.g. bleeding or hemorrhage). When the services described by CPT codes as complications of a primary procedure require a return to the operating room, they may be reported separately; generally, due to global surgery policy, they should be reported with the -78 modifier indicating that the service necessary to treat the complication required a return to the operating room during the postoperative period. When a complication described by codes defining complications arises during an operative session, however, a separate service for treating the complication is not to be reported. An operative session ends upon release from the operating or procedure suite (as defined in MCM '4821)."

Hope that helps!