ED Coding and Reimbursement Alert

Hint: Differentiate simple from complex to nail the coding rules.

When patients present to the ED with nosebleeds, it can be challenging to determine the right code to report, since CPT^® contains five nasal hemorrhage-control codes. However, if you understand simple versus complex, initial versus subsequent, and when to code endoscopic hemorrhage control, you’ll be on the path to swifter payment.

Check out these five quick tips to put you on the path to accurate nosebleed control coding.

1. File 30901-30903 for Frontal Bleeding

In many cases, the ED provider will use cautery and/or packing to control anterior bleeding. In these cases, you should report 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).

Choose the appropriate code based on the hemorrhage-control amount and nosebleed severity. If the physician applies cautery and/or packing to limited nasal frontal areas, submit 30901. For difficult-to-control hemorrhages or multiple bleed areas, assign 30903.

Keep in mind: If you don’t perform cautery and/or packing, you cannot report 30901 or 30903 — instead, you should include the service in your ED E/M code for that date. The AMA noted in the July 2020 edition of CPT^® Assistant, “If the physician or other qualified health care professional placed material (eg, cottonoid or gauze) with topical anesthetic and/or decongestant into the nose for a short time with the intent to identify the bleeding site, removed it with no ensuing bleeding or concerning lesion identified, and there was no cautery performed or packing left in place to remain after the encounter, the appropriate E/M service should be reported.”

2. Assign 30905-30906 for Posterior Bleed Control

CPT^® designates a separate code set for treating nosebleeds that occur in the back of the nose (30905, Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial; and 30906, … subsequent). Don’t apply the above limited/difficult criteria to these codes.

Better way: Select the right code based on the patient’s status. The first time the provider controls a patient’s back-of-the-nose (nasopharynx) bleeding, report 30905. If bleeding reoccurs at that site and the ED provider repeats posterior cautery and/or packing, submit 30906.

Keep in mind that there’s no guarantee that your insurer will pay for both packings or cauterizations. Your chart notes should clearly describe the circumstances and emphasize that the patient’s condition was not resolved, and a second treatment was therefore medically necessary.

3. Code Epistaxis Per Side and Visit

Because the National Correct Coding Initiative (NCCI) bundles 30901 and 30903 into 30905, you should submit only one same-side hemorrhage-control code for each encounter. So if your provider performs anterior and posterior packing, report only 30905.

In addition, the NCCI bundles 30905 into 30906. Therefore, if a patient requires initial and subsequent posterior bleed control, you should report 30906.

Quick tip: Use modifier 50 (Bilateral procedure) for bilateral epistaxis control. Because 30901-30905 represent unilateral codes, you should report cauterization per side.

For instance, suppose a patient requires limited left and right anterior packing. Assign 30901-50 to indicate that the ED provider packed each nasal passage. Alternatively, you can use modifier XS (Separate structure…) or 59 (Distinct procedural service) for separate-side bleed control, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Example: Suppose your ED physician performs simple anterior cautery on a patient’s right nostril and anterior complex packing on the left side. Submit the claim as 30903, 30901-59. Modifier 59 tells the insurer that the complex hemorrhage control occurred on a different side from the simple cautery. If the payer processes the modifiers for laterality properly, instead of modifier 59, you can use the appropriate LT and RT modifiers (such as 30903-LT and 30901-RT). But this option is only available with payers who do not bundle procedures when the separate sites are identified with body area modifiers as available in the CPT^® Appendix A.

4. Reserve 31238 for Scope-Necessary Cautery

Now that you know the four main epistaxis-control codes’ requirements, you may wonder when to charge the endoscopy codes. What fulfills 31238’s requirements?

You should report 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage) when the ED provider can’t stop the bleeding without the endoscope. But the physician can’t simply use the scope as an aid to see the area. They must use the endoscope to control epistaxis.

Example: A patient presents to the ED with a bleeding nose. The provider performs nasal endoscopy (31231) to locate the source of the bleeding, and then extensively cauterizes the patient’s nasal anterior region. In this case, submit only the surgery code (30903).

Do not code 31231 along with 30903 because the diagnostic nasal endoscopy code (31231) is bundled with all of the above control of nasal epistaxis codes 30901-30906. When the physician is using the nasal endoscope only for visualization, you should not use 31238. In the above description, the provider did not place the electrocautery tool parallel to the endoscope to burn the nasal tissues. If, however, the physician uses the scope to control the bleeding and the documentation shows that the endoscope was not just used to locate the site of the bleed, you should submit 31238.

Pro tip: You shouldn’t separately report the cautery. Code 30903 is incidental to 31238.

5. Apply Endoscopy Edit to 30901-30906

In the above cautery example, don’t be tempted to bill both the surgery and the diagnostic procedure. NCCI bundles 30901-30906 into 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]).

Pay attention: This is a backward edit. The NCCI usually bundles the diagnostic procedure (31231) into the surgery (30901-30906), not the other way around. Thus, when your physician performs a diagnostic endoscopy prior to cautery and/or packing, you should report the higher-valued code.

Careful: All hemorrhage control codes except 30901 ($58.27) pay more than endoscopy (31231), which reimburses $63.81. So when your physician performs endoscopy prior to epistaxis control (codes 30903, which pays $237.60 and 30906, which pays $397.43), you should submit the surgical procedure. But when they use endoscopy prior to simple cautery, report the diagnostic procedure because it pays more.