CPT 42962 Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

CPT 42962: Postoperative Oral and Pharyngeal Hemostasis

CPT code 42962 denotes a surgical procedure to control bleeding in the mouth and pharynx after procedures such as tonsillectomy, performed as an urgent primary intervention within 24 hours or as a secondary procedure up to two weeks postoperatively. Nationally, this code captures acute postoperative airway and bleeding management events that have implications for hospital resource use, surgical follow-up, and quality reporting. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find: a clear clinical context for when CPT code 42962 is reported; the typical sites of service where the procedure is performed; common billing modifiers associated with perioperative and emergent surgical services; and discussion of payer coverage patterns and claims considerations where available. The summary highlights how the code is used to document interventions for postoperative hemorrhage in the oral cavity and pharynx, and outlines what to expect in claims workflows and policy reviews. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 42962postoperative hemorrhagetonsillectomy complicationshead and neck surgerysurgical hemostasisoperative billingENT procedureemergent surgical care

Billing Code Overview

CPT code 42962 describes a surgical procedure to control hemorrhage in the oral cavity and pharynx occurring within 24 hours (primary) or up to two weeks (secondary) after operations such as tonsillectomy. The procedure involves direct surgical means to achieve hemostasis in the mouth and throat following postoperative bleeding.

Service type: Surgical hemostasis procedure
Typical site of service: Operative suite or ambulatory surgical center; may also occur in hospital inpatient or emergency department settings depending on timing and clinical urgency.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is a child or adult who returns to the emergency department or ambulatory surgical center with postoperative hemorrhage following a tonsillectomy or related oropharyngeal procedure. The patient presents within 24 hours (primary) or up to two weeks (secondary) after the original surgery with active bleeding from the tonsillar beds, oropharynx, or posterior pharynx, accompanied by visible blood in the mouth, hematemesis, or hemodynamic instability. Initial triage includes airway assessment, vital signs, IV access, fluid resuscitation, and laboratory studies (complete blood count, coagulation panel, type and screen). If bleeding persists or is brisk, the otolaryngology surgeon performs a focused operative procedure in the operating room or procedure suite to identify and control the bleeding source using surgical techniques such as cauterization, suture ligation, topical agents, or electrocautery. The procedure often requires general anesthesia, suctioning of blood and clots, and documentation of the timing relative to the index tonsillectomy (primary within 24 hours or secondary up to 14 days). Postoperative care includes airway monitoring, observation for recurrent bleeding, pain control, and communication with the surgical and anesthesia teams and the patient’s payer for authorization and billing documentation.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the procedure required substantially greater effort or complexity than usual (extensive bleeding control, prolonged operative time).

CPT 42970: Simple Control of Postoperative Nasopharyngeal Bleeding

CPT-42961-OROPHARYNGEAL-POSTOPERATIVE-HEMORRHAGE-CONTROL-HOSPITAL

CPT 42961: Control of Postoperative Oropharyngeal Bleeding, Inpatient

CPT-42972-NASOPHARYNGEAL-BLEEDING-CONTROL-POST-ADENOIDECTOMY

CPT 42972: Surgical Control of Postoperative Nasopharyngeal Bleeding

CPT-42999-UNLISTED-PHARYNX-ADENOIDS-TONSILS-PROCEDURE

CPT 42999: Unlisted Pharynx, Adenoids, or Tonsils Procedure

CPT-42960-OROPHARYNGEAL-BLEEDING-CONTROL-POSTOPERATIVE

CPT 42960: Control of Postoperative Oropharyngeal Bleeding

CPT-42975-ENDOSCOPIC-AIRWAY-EVALUATION-SLEEP-DISORDERED-BREATHING

CPT 42975: Endoscopic Airway Evaluation During Sedation

CPT-42971-NASOPHARYNGEAL-BLEEDING-CONTROL-POST-ADENOIDECTOMY

CPT 42971: Inpatient Control of Postoperative Nasopharyngeal Bleeding

CPT-42955-PHARYNGOSTOMY-LONG-TERM-FEEDING

CPT 42955: Pharyngostomy for Long-Term Enteral Feeding

Taxonomy Code	Specialty	Notes
207L00000X	Otolaryngology	Primary specialty performing tonsillar hemorrhage control procedures.
207K00000X	Otolaryngology - Pediatric	Pediatric-focused surgeons for tonsillectomy complications in children.
208D00000X	General Surgery	General surgeons may manage severe oropharyngeal bleeding in some settings.
207T00000X	Neurotology	May be involved for complex head and neck bleeding cases (less common).
363A00000X	Anesthesiology	Provides anesthesia management for operative control of bleeding.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`J35.3`	Hypertrophy of tonsils and adenoids	Common indication for tonsillectomy; postoperative bleeding can occur after this index surgery.
`J03.90`	Acute tonsillitis, unspecified	Infection leading to tonsillectomy or complicating postoperative healing with potential bleeding.
`K92.2`	Gastrointestinal hemorrhage, unspecified	May be used for documented hematemesis when source is oropharyngeal bleeding presenting as GI bleeding symptom.
`R04.0`	Epistaxis	Differentiates nasal bleeding from oropharyngeal sources when both nasal and oropharyngeal bleeding are considered.
`T81.0XXA`	Hemorrhage and hematoma complicating a procedure, initial encounter	Used to indicate postoperative hemorrhage related to the surgical procedure.
`Z48.02`	Encounter for removal of sutures and staples	Relevant when return to OR requires removal or revision of prior surgical site closures.
`Z98.890`	Other specified postprocedural states	Captures postoperative status when coding for complications of prior head and neck surgery.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`42826`	Tonsillectomy and adenoidectomy; younger than 12 years, with or without cautery	Often the index procedure after which postoperative hemorrhage requiring `42962` can occur.
`42820`	Tonsillectomy, primary; younger than 12 years, without adenoidectomy	An index surgery commonly preceding postoperative bleeding events addressed by `42962`.
`30901`	Excision of tonsillar tissue, peritonsillar abscess drainage	Performed for related oropharyngeal infections that may complicate bleeding control or present in the differential.
`99284`	Emergency department visit, moderate to high severity	Common E/M code for ED evaluation preceding the operative control of bleeding.
`99100`	Anesthesia for emergency major surgery or trauma, not otherwise specified	May be used for anesthesia billing when emergent operative control of bleeding is performed.
`36415`	Collection of venous blood by venipuncture	Common ancillary service for preoperative labs during evaluation and stabilization prior to `42962`.

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