ED Coding and Reimbursement Alert

From Minnesota tube to epistaxis control, test yourself on these scenarios.

Emergency departments are on the front lines of bleeding control services for a variety of conditions, from stab wounds to nosebleeds to vomiting blood. When it comes to controlling the flow, coding can get tricky. Test yourself with these three scenarios and see if you can select the right code before you check out the answer.

Scenario 1: Epistaxis Control

A patient presents to the ED with a nosebleed following an accidental head-butt by his brother. The ED physician has the patient hold an ice pack to his nose while the physician asks the nurse to bring nasal packing materials to the patient’s bedside. When the physician returns to check on the patient, the bleeding has subsided and packing is not necessary. Which code should you report?

Solution: Although most EDs are accustomed to reporting 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) or 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) for most epistaxis patients, those codes are not necessary in this situation.

“If simple procedures like ice and pressure succeed by themselves, E/M is appropriate,” says Chip Hart of consulting firm PCC in Vermont. Therefore, the appropriate code should be selected from the 99281-99285 range based on the documentation of the encounter.

Scenario 2: Minnesota Tube Placement

A patient presents with bleeding from her mouth and nostrils, and an NG tube is placed with return of bloody gastric contents. A Minnesota tube is passed into the proximal stomach and the esophageal balloon is inflated, ceasing the bleeding from her mouth.

Solution: A Minnesota tube consists of a flexible plastic tube containing multiple channels, inflatable balloons, an opening at the bottom (gastric tip) of the device and an opening near the upper esophagus, says Todd Thomas, CPC, CCS-P, president of ERcoder, Inc., in Edmond, Oklahoma. The tube is passed down into the esophagus and the gastric balloon is inflated inside the stomach. Traction is applied to the tube so that the gastric balloon will compress the gastroesophageal junction and reduce the blood flow to esophageal varices. If the use of traction alone cannot stop the bleeding, the esophageal balloon is also inflated to help stop the bleeding.

To report this service, you’ll use 43460 (Esophagogastric tamponade, with balloon [Sengstaken type]), Thomas says. “The CPT^® code specifically lists a Sengstaken tube (also known as a Sengstaken–Blakemore tube) -- the Minnesota tube is a more modern version of the device that performs in the same manner.”

Scenario 3: Bleeding From Stab Wound in Arm

A patient is brought to the ED with a stab wound to his arm. The ED physician notes venous bleeding due to a transected blood vessel and ligates it with 3-0 silk structure. The bleeding subsides.

Solution: Ligating the artery of an extremity to control bleeding is best coded using 37618 (Ligation, major artery [eg, post-traumatic, rupture]; extremity). Although the question doesn’t include complete documentation, it’s possible that in this case, the patient’s condition might necessitate critical care (99291,  Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Don’t overdo it: You shouldn’t report a critical care code for a normal control-of-bleeding situation or if the physician causes the bleeding. In this example, however, the patient may meet the definition of being critically ill due to the severity of the bleeding.

Keep in mind that only one physician may bill for critical care during any single time period, even if more than one physician is providing care. Therefore, if a critical care physician or hospitalist also attended to the patient, the ED physician may not be able to bill the critical care code.