ED Coding and Reimbursement Alert

Separate E/M almost a give for anterior ED repairs.

Patients reporting to the ED for treatment of an anterior nosebleed pose a challenge for the coder, who might choose an E/M code ... or a procedure code ... or both.

If you miss an opportunity to report an E/M code and a procedure code, it could cost your ED deserved reimbursement. Here's the lowdown on the best practices for IDing treatment types on your anterior nosebleed treatments.

Convert Conventional Stops to E/M Code Only

If a patient reports to the physician with a nosebleed and the provider stops the bleeding with very simplified methods, you should choose an E/M code for the entire encounter, confirms Jeffrey Linzer Sr., MD, FAAP, FACEP, Associate Medical Director for Compliance, Emergency Pediatric Group, Children's Healthcare of Atlanta at Egleston.

This means you have to be on guard for nosebleed treatments that don't qualify as separately reportable nosebleed (epistaxis) services, for coding purposes. Standard nosebleed-stoppage methods, "including direct pressure, ice, pinching the nostrils closed, etc., are all basic services that should be included in the E/M," relays Joshua Tepperberg, CPC, EMT-D, coding team leader at Caduceus Inc. in New York City.

Example: A 58-year-old woman reports to the ED with a nosebleed she reports has been occurring "off and on" all morning. The nonphysician practitioner (NPP) uses gauze and direct pressure and stops the bleeding. Notes indicate an expanded problem focused history and exam, along with low-complexity medical decision making.

On the claim, you'd report the following:

99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity...) for the nosebleed treatment

784.7 (Epistaxis) appended to 99282 to represent the patient's nosebleed.

Explanation: Even though the NPP stopped a nosebleed in this instance, the treatment methods do not elevate it to a separately reportable procedure.

Tool Use Can Guide You to 30901

There are other instances in which the ED provider will provide a separately reportable procedure in order to stop an anterior nosebleed; when this occurs, you'll frequently report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), says Linzer.

The methods, and implements, that the provider uses to stop a nosebleed are the biggest clues as to whether a procedure occurred. "Either heat or chemical cautery would support this code, as would packing says Sharon Richardson, RN, compliance officer with Emergency Groups' Office in Arcadia, Calif.

(Note: For a list of clues that could key you into a 30901 service, see "Term Knowledge Can Correct Nosebleed Fix Claims" on page 20.)

30901-E/M Worth $60 More

If you are submitting 30901 claims, you might want to double-check the claim for evidence of a separate E/M service. Sure, all procedures have a built-in E/M component, but in the ED the provider will almost certainly check the patient for other injuries or medical problems, such as evidence of a bleeding tendency, before performing a simple nosebleed treatment.

The $kinny: Let's say a patient reports to the ED suffering from epistaxis and requires simple anterior nosebleed treatment. You do not identify the 30901 service, and instead bundle the entire service into the E/M work. If you'd also coded 30901, you could have gotten paid for the ED E/M and 30901, which currently reimburses about $60 (1.69 transitioned facility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846).

Check Out This Case Study

If you're curious about detailed clinical scenarios, consider this example from Tepperberg, which illustrates an E/M-30901 combo encounter: An 18-year-old male presents to the ED after getting punched in the face in a street assault; he is dizzy and has blood dripping from his nose, but the patient is alert and oriented to person, place, and time. The patient denies loss of consciousness, cervical-spine tenderness, or any other complaint.

The MD conducts her exam, during which she notes no other injuries; also, the patient's vital signs are within normal limits except for an increased pulse (104 bpm). Further, notes indicate normal heart sounds, normal motor, sensory, pulse, and strength. Other than being very agitated, as he was assaulted by a stranger, the patient appears uninjured aside from the nosebleed, which will not stop with traditional methods. Notes indicate a level-three ED E/M service.

Under direct visualization and a rhinoscope, the physician finds a small bleed inside the anterior chamber of the right nostril. She performs electrical cauterization and achieves hemostasis, which stops the bleeding after 10 minutes. The physician discharges the patient with instructions on how to care for the injury, and instructions to return to the ED immediately if the bleeding starts again or if there are any other issues or complications.

For this encounter, you'd report the following:

• 30901 for the nosebleed repair
• 99283 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M
• 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 99283 to show that the E/M and repair were separate services
• 784.7 appended to 30901 and 99283 to represent the patient's nosebleed
• 920 (Contusion of face, scalp, and neck except eye[s]) appended to 30901 and 99283 to represent the patient's facial bruise
• E960.0 (Fight, brawl, rape) appended to 30901 and 99283 to represent the cause of the patient's injury
• E849.5 (Place of occurrence; street and highway) appended to 30901 and 99283 to represent the where the injury occurred, geographically.

Remember: On all E/M plus 30901 claims, you should include "a procedure note, separate from an E/M documentation, showing that the bleed was stopped with packing or cautery," advises Linzer.