ED Coding and Reimbursement Alert

You-ll need detailed notes from the physician to justify a  complex repair code

When a patient presents to your ED with a nosebleed, you-ll have to pinpoint the extent of the treatment before deciding on the proper code. The answers you seek should show up in the op notes for the encounter, and your ED physician should be very specific about his actions and the methods he used to stop the bleeding.
 
Consider Reporting a Low-Level E/M

While CPT has several codes to describe different types of nosebleed treatment, you-ll have to meet certain criteria to use them. And you won't report all nosebleed treatments with procedure codes--sometimes, an E/M services is all you should report, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill.

When? If the physician succeeds in stopping the nosebleed with conventional methods, such as ice or pressure, the service will likely only qualify as an E/M, Gilhooly says.

-The physician has to go past the normal means of stopping a nosebleed- to use the procedure codes, she says.

Mull Over 30901 for Nitrate Stick Use

If the physician must use more complicated means to stop the bleed, he may be performing a simple anterior repair, which you would report with 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), says Elijah Berg, MD, FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass.

-You would report 30901 when there has been minimal cautery performed or something less than the entire anterior nasal vestibule has been packed. This might involve a few dabs with a silver nitrate stick or use of some small pledgets,- Berg says.

Example: A 25-year-old female presents to the ED with a moderate nosebleed. Upon interviewing her, the physician finds that the patient has had them before, but this one has lasted for 45 minutes. The physician identifies a small area of bleeding and performs limited cautery with a silver nitrate stick to stop the bleeding.

On the claim, you should:

- report 30901 for the nosebleed repair.

- attach 784.7 (Epistaxis) to 30901 to prove medical necessity for the repair.

When you are reporting nosebleed fixes in the ED, Gilhooly says, you should include a detailed procedure note on the claim.

-One of the deficits I see sometimes is that the physician just says -controlled nosebleed- in the report. You need to have a separate procedure note because there are many things that could cause the nosebleed,- she says.

Try this: Gilhooly says some of the descriptions the physician might include in a procedure note for 30901 include:

- indications for the procedure

- techniques the physician used to stop the bleeding

- how the patient responded to these techniques

- which medical professional performed the procedure.

Identify 30903 Claims by -Extensive Packing-

At times, limited cautery or packing is not enough to stop an anterior nosebleed. When the physician has to use more extensive packing or cautery, you may be able to report 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) instead of 30901.

Benefit: Payouts are higher for extensive fixes. According to Berg, 30901 pays about $62 per encounter, while 30903 pays about $82 per encounter.

But how will you identify 30903 claims? -Preformed nasal packs that fill nearly the entire anterior nasal vestibule are now commonly used in EDs,- Berg says. When your physician uses one of these -nasal tampons- to stop the bleeding, it usually qualifies as an extensive anterior repair.

-Also, more formal nasal packing with yards of Vaseline gauze would also qualify as extensive packing,- which you would code with 30903, Berg says.

-Extensive cautery would involve cauterizing several areas with the possibility of involving multiple bleeding episodes and several attempts to control the hemorrhage,- he says. If the procedure notes indicate that the physician performed extensive packing or cautery during the encounter, you may be able to report 30903.

Example: A patient presents with several hours of moderate intermittent nosebleeding that has not resolved with pressure. There has been no other bleeding and no bruising. A medication history reveals that the patient is on aspirin. The physician packs the anterior chamber with a preformed pack, prescribes a short course of antibiotics, and instructs that the packing be removed in 24 hours.

On the claim, Berg says, you should:

- report 30903 for the nosebleed repair

- report the proper level E/M service code (this will vary depending on the patient's individual condition, payer and region)

- attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code to show that it was a separate service from the repair

- attach 784.7 to 30903 and 99283 (ED visit ...) to prove medical necessity for both services.

Documentation alert: When you are filing a claim with 30903, Gilhooly recommends that you include:

- a description of the severity of the nosebleed

- a description of the extent of the nosebleed

- a description of how the nasal hemorrhage was -complex-

- a description of what -extensive- cautery or packing the physician provided.

-From a coder's perspective, I expect to see the physician be very descriptive on 30903 claims,- Gilhooly says.