ED Coding and Reimbursement Alert

ED coders often under-report their ED's epistaxis claims.

If you can't differentiate a complex anterior nosebleed repair from a simple one, you-re costing your ED nearly $20 per misidentified claim.

Further, coders who cannot discern a reportable nosebleed repair encounter from an E/M will subject the practice to upcoding concerns. Check out these basics for each type of nosebleed repair to nail your coding each time.

If a patient reports to the ED with a nosebleed, and the physician stops the bleeding with basic methods, the coder usually chooses an E/M code,confirms Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla.

These methods can include minimal attempts at stoppage, including ice or brief, direct pressure. The key to these encounters is that the physician did "not perform a billable procedure, so the E/M is the only way to capture the services the physician provides," Martien explains.

Also: Any treatment of an active nosebleed is likely going to trigger the assignment of a nosebleed repair code, relays Todd Thomas, CPC, CCS-P, president of ERcoder Inc. in Edmond, Ok.

"There are patients that present [to the ED] with a complaint of a nosebleed, but there is no active bleeding. In that situation, only the E/M would apply," says Thomas.

Several factors can up the nosebleed fix to the level of procedure, according to Thomas. You might be able to report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) if the notes indicate that the ED physician performed one of the following to treat a nosebleed:

- applied continuous pressure

- inserted pledgets soaked with an anesthetic-vasoconstrictor solution into the nasal cavity

- administered nasal spray to anesthetize/shrink nasal mucosa

- performed chemical cautery with a silver nitrate stick.

Key terms: When deciding on a nosebleed repair code, "look for phrases such as -hemostasis- (control of bleeding), -bovie,- -silver nitrate,- -electrocautery,- and -chemical cauterization.- These terms would indicate a procedure," relays Martien.

Example: A patient presents to the ED with an active nosebleed. The physician anesthetizes the nasal mucosa with Cetacaine, and cauterizes the septum area with silver nitrate to stop the bleeding.

This is a simple anterior repair, confirms Thomas. On the claim, report 30901 with 784.7 (Epistaxis) appended.

Remember: If the ED physician treats bleeding on both sides of the patient's nose, report the nosebleed repair code (30901, 30903) with modifier 50 (Bilateral procedure) appended.

ED physicians will also perform complex anterior nosebleed repairs, says Martien. You-ll have to dig through the notes to identify complex repairs, but the extra work will pay off.

An easy $20: The average payout for 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) is approximately $77 per claim (2.13 relative value units [RVUs] using the 2009 Medicare Physician Fee Schedule multiplied by Medicare's conversion rate of 36.0666). Code 30901 pays approximately $59 per claim (1.64 RVUs).

There are several scenarios that might indicate a complex repair. You should consider 30903 when the physician makes several attempts to stop the bleeding, either via the same method or different methods. Also, the physician might use "more aggressive treatment" on complex nosebleed repairs, Thomas says. These methods include traditional nasal packing (gauze), a prefabricated nasal sponge, or an epistaxis balloon.

Consider this detailed clinical scenario from Martien:

A 12-year-old boy reports to the ED with a nosebleed that started about 30 minutes ago; he was chasing his brother through the house and ran into a sliding glass door he thought was open. Notes indicate he hit face first and suffered trauma to his nose, brow, and chin from the impact with the door and subsequent fall.

There is frank bleeding from both nares, and erythema and bruising to the patient's left brow and chin, but no broken skin. The physician cleans off the blood and examines the nares, finding several small areas of bleeding from the internal mucosa but no fractures -- a fact confirmed by an x-ray. ED staff places nasal tampons before the x-ray, then has to replace them when the patient returns to the ED. Before the patient achieves satisfactory hemostasis, the ED physician replaces the tampon, ultimately packing the entire nasal vestibule. Once bleeding abates, the physician gives the patient detailed discharge instructions and sends him home.

This is a complex repair, Martien confirms. On the claim, report the following:

- 30903-50 for the repair

- 9928x for the E/M service (check encounter notes for E/M level)

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 9928x to show that the E/M and repair were separate services

- 784.7 appended to 30903 and 9928x to represent the patient's nosebleed

- E917.8 (Striking against or struck accidentally by objects or persons; other stationary object with subsequent fall) appended to 30903 and 9928x to represent the cause of the patient's injury

- E849.0 (Place of occurrence, home) appended to 30903 and 9928x to represent where the accident took place.