ED Coding and Reimbursement Alert

Check the chart carefully to see if a separate procedure is warranted for nose bleed presentations.

Many patients present to the ED complaining of a nosebleed, but not all of them should be billed for treatment of epistaxis. 

Some patients present due to epistaxis but are not actively bleeding in the ED.  In these encounters the physician may not perform a billable procedure, so you would report only the E/M to identify the services the physician provides, explains Todd Thomas, CPC, CCS-P, President of ERcoder, Inc., in Edmond, OK.  

Even some presentations with minor active bleeding may not support reporting a procedure code for treatment when the physician directs the patient in self-administered home remedies such as patient applied ice, direct pressure, etc.  Any physician treatment of an active nosebleed is likely going to support the assignment of a nosebleed treatment CPT® code, Thomas adds. 

Choice of Method Marks Most 30901 Claims

Several factors can qualify 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:

• Performed chemical cautery with a silver nitrate stick; 

• Performed brief electro-cautery; or

• Packed the nose with pledgets or a limited amount of gauze.

You would not report 30901 if the physician treatment was limited to:

• Applied continuous pressure;

• Administered nasal spray to anesthetize/shrink nasal mucosa.

Key terms: When deciding on a nosebleed treatment code, “look for phrases such as ‘hemostasis’ (control of bleeding), ‘bovie,’ ‘silver nitrate,’ ‘electrocautery,’ and ‘chemical cauterization.’ These terms would indicate a procedure, Thomas explains.

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

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

  If the ED physician treats bleeding on both sides of the patient’s nose, report the nosebleed treatment code (30901) with modifier 50 (Bilateral procedure) appended.

Technique and Complexity May Warrant 30903

Train ED physicians to accurately document their treatment methods and make sure ED coders know how to recognize the methods that support reporting 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).There are several scenarios that would indicate complex treatment. 

You should consider 30903 when the physician makes multiple attempts at “simple” treatments to stop the bleeding. Also, the physician might use “more aggressive treatment” on complex nosebleed treatments, Thomas says. These methods may include traditional nasal packing (gauze), a prefabricated nasal sponge, or an epistaxis balloon.

Consider this clinical scenario from Thomas:

Example 1: A 17-year-old reports to the ED with a nosebleed that started about 30 minutes ago from a face plant into the ground after getting tackled in a casual football game.  He is bleeding from both nares. The physician cleans off the blood and examines the nares, finding several small areas of bleeding from the internal mucosa but no fractures. He orders an x-ray for confirmation. He 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 stops, the physician gives the patient detailed discharge instructions and sends him home.

This is a complex treatment. On the claim, report the following:

• 30903-50 for the treatment

• 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 treatment were separate services

• 784.7 (Epistaxis) appended to 30903 and 9928x to represent the patient’s nosebleed

For ICD-10 report R04.0 (Epistaxis)

Add the E code for the injury, E886.0 (Accidental fall on same level from collision, pushing, or shoving by or with other person, in sports)

ICD-10 allows even greater specificity

Y93.61 (Activities involving other sports and athletics played as a team or group, American tackle football)

Example 2: Consider an epistaxis encounter where the physician performed bilateral anterior packings and on the right side posterior packing.  How would you report the procedures since they are not identical bilaterally?

Anterior packing is included in the posterior packing, so you cannot bill 30903 and 30905 together on the same side. For this scenario, report 30903-LT (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) on the side with anterior packing only, and 30905-RT (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial). While some payers may request the LT/RT designation others may require the 59 modifier to represent that 2 separate and distinct anatomical areas were treated.