How To Use CPT Code 42961

CPT 42961 describes the procedure for controlling oropharyngeal hemorrhage, both primary and secondary, that requires hospitalization. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 42961?

CPT 42961 involves the control of oropharyngeal hemorrhage, which can occur within 24 hours after a surgery such as a tonsillectomy. This procedure is complicated and requires hospitalization. The provider uses various techniques to control bleeding in the mouth and throat, which can be life-threatening if left uncontrolled.

2. Official Description

The official description of CPT code 42961 is: ‘Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring hospitalization.’

3. Procedure

1. After the patient is appropriately anesthetized, the provider assesses and controls heavy bleeding in the mouth and throat.
2. Hemostasis may be achieved using techniques such as bipolar electrocautery, hot water irrigation, or the application of specific chemicals.
3. The procedure is performed within 24 hours (primary) or up to two weeks (secondary) after a surgery, such as a tonsillectomy.
4. The provider carefully monitors the patient’s condition and ensures that bleeding is effectively controlled.
5. In cases where the bleeding is severe or difficult to control, hospitalization is necessary to provide the appropriate level of care.

4. Qualifying circumstances

CPT 42961 is used when the control of oropharyngeal hemorrhage is complicated and requires hospitalization. This procedure is typically performed within 24 hours (primary) or up to two weeks (secondary) after a surgery, such as a tonsillectomy. It is important to note that this code should not be used for cases where bleeding is not severe or control is simple.

5. When to use CPT code 42961

CPT code 42961 should be used when a provider needs to control oropharyngeal hemorrhage that is complicated and requires hospitalization. This code is specifically for cases where the bleeding occurs within 24 hours (primary) or up to two weeks (secondary) after a surgery, such as a tonsillectomy. It is important to accurately document the circumstances and severity of the bleeding to support the use of this code.

6. Documentation requirements

To support a claim for CPT 42961, the provider must document the following information:

• The patient’s diagnosis and the need for control of oropharyngeal hemorrhage
• The specific techniques used to achieve hemostasis, such as bipolar electrocautery, hot water irrigation, or the application of specific chemicals
• The date and time of the procedure
• The severity of the bleeding and the effectiveness of the control measures
• Any complications or additional interventions required
• The provider’s signature

7. Billing guidelines

When billing for CPT 42961, ensure that the procedure meets the criteria for a complicated case requiring hospitalization. It is important to accurately document the circumstances and severity of the bleeding to support the use of this code. Additionally, be aware of any specific payer guidelines or requirements for reporting this procedure.

8. Historical information

CPT 42961 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare payers.

9. Examples

1. A patient undergoes a tonsillectomy and experiences severe oropharyngeal bleeding within 24 hours. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
2. Following a tonsillectomy, a patient develops secondary oropharyngeal bleeding two weeks after the surgery. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
3. During a tonsillectomy, the patient experiences life-threatening oropharyngeal bleeding. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
4. After a tonsillectomy, the patient develops severe oropharyngeal bleeding that cannot be controlled using simple measures. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
5. A patient undergoes a tonsillectomy and experiences significant oropharyngeal bleeding within 24 hours. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
6. Following a tonsillectomy, a patient develops secondary oropharyngeal bleeding two weeks after the surgery. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
7. During a tonsillectomy, the patient experiences life-threatening oropharyngeal bleeding. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
8. After a tonsillectomy, the patient develops severe oropharyngeal bleeding that cannot be controlled using simple measures. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
9. A patient undergoes a tonsillectomy and experiences significant oropharyngeal bleeding within 24 hours. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.
10. Following a tonsillectomy, a patient develops secondary oropharyngeal bleeding two weeks after the surgery. The provider performs CPT 42961 to control the bleeding, which requires hospitalization.