PROCEDURAL NOTE
PATIENT: Ortiz, Pamela
AGE: 13
DATE: 01/19/2016
PREOPERATIVE DIAGNOSIS: Oropharyngeal Hemorrhage s/p Tonsillectomy
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Control of oropharyngeal hemorrhage
The patient was seen in the emergency room one day after tonsillectomy due to uncontrolled oropharyngeal hemorrhage. The patient was admitted to the hospital for control of nasal hemorrhage and observation. The suture site from tonsillectomy was visualized and the pharynx was packed with gauze to control any additional bleeding. The patient remained in hospital for an additional 24 hours under observation and to control any additional hemorrhaging. The physician recommended the patient schedule a follow-up appointment in two days to check the sutures.
How should you code this procedure?
Explanation
Answer: B - You should code this procedure using code 42961 (Control Oropharyngeal Hemorrhage, Primary or Secondary (e.g. Post-Tonsillectomy); Complicated, Requiring Hospitalization). The notes indicate that the patient was admitted to the hospital for observation, so the code 42960 (Simple Control) is not appropriate. In addition, code 42962 refers to a secondary surgical intervention, but in this case, no other surgical interventions were noted.
