ED Coding and Reimbursement Alert

Certain methods may signal a more complex treatment

When your ED physician treats a patient's nosebleed, you may be tempted to turn immediately to the nasal hemorrhage treatment CPT codes.

But rushing to use those codes may be premature, experts say. Before choosing a nosebleed treatment code, check the operative notes to see if the encounter meets CPT parameters for nasal hemorrhage treatment.

Physician Could Perform E/M to Treat Nosebleed

You-ll end up coding a portion of your nosebleed presentations in the ED with an appropriate E/M code, says Michael Granovsky, MD, CPC, president of MRSI, an ED coding and billing company in Woburn, Mass. If the physician is able to stop the bleeding with standard methods such as ice or pressure, you should report the service with an E/M code.

Example: A patient presents with mild left nasal bleeding. The physician performs an extended problem-focused history and exam, and applies 10 minutes of direct pressure to the left nostril. After the pressure, a repeat assessment shows that the bleeding has stopped.

In this instance, you should report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the treatment, Granovsky says.

Also, attach 784.7 (Epistaxis) to 99283 to represent the patient's nosebleed.

Limited Packing Indicates Simple Treatment

When the nosebleed requires more substantial and invasive methods to be controlled, such as minimal cautery or nasal packing, you-ll be able to report the service with 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method). 

Report this code for nosebleed treatments that involve -one attempt at cautery or placement of packing in the anterior part of the nostril that controls the bleeding on the first try,- says Robert La Fleur, MD, FACEP, an emergency medicine physician and president of Medical Management Specialists in Grand Rapids, Mich.

Consider this example from La Fleur: A 7-year-old boy who picks at his nose is brought to the ED by his mother. The mother says the boy's right nostril started bleeding two hours ago, and she cannot stop it.

During the course of a level-two E/M service, the physician finds that the patient is otherwise healthy and has no other bleeding problems. The physician examines the patient and discovers persistent ooze from the septum during a check of the right naris.

The ED physician places cotton strips soaked in Pontocaine and Epinephrine in the patient's right naris for 15 minutes. There is an obvious bleeding site after the physician removes the strips, which he cauterizes with a silver nitrate stick.

This is an example of a simple anterior treatment, La Fleur says. On the claim, report the following:

- 30901 for the nosebleed treatment

- 99282 (- an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low 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) attached to 99282 to show that the E/M was separate from the nosebleed treatment

- 784.7 linked to 30901 and 99282 to prove medical necessity for both services.

Documentation alert: On your 30901 claims, -the procedure note should reflect the type of treatment provided, such as cautery or packing,- Granovsky says.

Multiple Attempts Might Signal Complex Treatment

When your ED physician treats a patient with a more serious nosebleed, he may need to try several different methods, or the same method several times, to stop the bleeding. In these cases, you might be able to report 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) for the nosebleed treatment.

Code 30903 describes -any episodes that were difficult to control or that did not respond promptly to the initial attempts and required multiple interventions,- La Fleur says. If the bleeding was severe enough to make localization of the bleeding site difficult, you might also consider reporting 30903, La Fleur says.

Techniques used: When your physician performs an extensive treatment, the technique involves more significant therapies such as packing with Merocel, nasal packing with Vaseline, gauze or nasal tampons, Granovsky says.

Example: A 45-year-old female presents to the ED with moderate bleeding from the right nostril. The physician performs an expanded problem-focused history and physical exam. Upon evaluating the right naris, she notes that there is significant bleeding from several areas, which appear inflamed and abraded. The physician packs the entire right nares with a nasal tampon.

For this encounter you would report the following:

- 30903 for the nosebleed treatment

- 99283 (... an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) with modifier 25 attached for the E/M

- 784.7 linked to 30903 and 99283 to prove medical necessity for the services.

Explanation: Code 30903 reflects the fact that the procedure required extensive packing (filling most of the nasal vestibule on that side), Granovsky says.