ED Coding and Reimbursement Alert

Here's why coding 30901 for ice stoppage might not be proper.

A patient reports to the ED with a nosebleed. The ED physician stops the nosebleed. The coder reports 30901, right?

Not so fast: Reporting 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) automatically could go wrong in two ways:

First, you could be overcoding. Second, if the physician performs a complex nosebleed repair and you report 30901, you're shorting the practice by about $24 per encounter.

Sidestep the bleeding of your bottom line with this expert advice on coding for patients with nasal hemorrhages.

Minimal Stoppage Techniques Are E/M Territory

Coders need to check how involved repair was before choosing a nosebleed repair code, as some nosebleed fixes are actually E/M services, confirms Kathy Plato, CPC, director of coding education & credentialing at ebix, Inc., headquartered in Wisconsin.

If a patient reports to the physician with a nosebleed, and the physician stops the bleeding with standard, minimal methods such as ice or pressure, the coder should choose an E/M code, Plato says.

When the stoppage methods are minimal, "no billable procedure was performed,"says Jeffrey Linzer Sr., MD, FAAP, FACEP, associate medical director for the compliance emergency pediatric group at Children's Healthcare of Atlanta at Egleston.

Solution: Roll the work into the overall ED E/M level.

Example: A patient reports to the ED with a nosebleed. She says it has been bleeding "off and on" for about two hours. The physician performs an expanded problem focused history and examination, and then applies pressure to the right nostril for two minutes. The bleeding abates, and the physician discharges the patient.

In this instance, you would report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination;and medical decision making of low complexity ...) for the entire encounter.

Nitrate Sticks, Cautery Mark CPT-Level Fixes

If the notes indicate that the encounter involved more extensive stoppage techniques -- such as a small amount of cautery or packing -- you'd choose 30901 for the service, along with any E/M service that the physician might provide, Plato relays.

"There would need to be a procedure note, separate from the E/M documentation, if applicable, showing that the bleed was stopped with packing or cautery," Linzer says.

Also: "A more detailed service, such as silver nitrate, could [warrant 30901]. The ED provider might additionally use a vasoconstrictor solution," adds Plato.

Example: A patient reports to the ED with a nosebleed he received after colliding head-on with his son during horseplay. The patient says it has been bleeding steadily for about four hours and he rates the pain 7 on a scale of 10. During a level-three E/M service in which she rules out a fractured nose, the physician diagnoses epistaxis. Using a few swabs with silver nitrate sticks, the physician stops the bleeding. She then prescribes pain medication and sends the patient home.

For this encounter, you'd report the following:

• 30901 for the repair
• 99283 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate 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) appended to 99283 to show the nosebleed repair and E/M were separate services
• 784.7 (Symptoms involving head and neck; epistaxis) appended to 30901 and 99283 to represent the patient's nosebleed.

Rhinorocket Might Shoot Claim to 30903

Your ED physician might also perform a complex anterior nosebleed repair, which you'd code with 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).

"A complex nosebleed repair would be more aggressive, such as difficulty stopping the bleed, nasal packing, maybe a rhinorocket or an epistaxis balloon," Plato says.

Example: A 54-year-old patient with a history of essential hypertension and taking blood thinners presents with a gushing nose bleed following a prolonged sneezing fit.

The ED physician performs an expanded problem focused history and physical exam to determine the site of the bleed. The physician then provides topical anesthesia and places a rhinorocket to control the bleeding.

For this encounter, you'd report the following:

• 30903 for the repair
• 99284 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M
• Modifier 25 appended to 99284 to show the nosebleed repair and E/M were separate services
• 784.7 (Symptoms involving head and neck; epistaxis) and 401.9 (Essential hypertension, unspecified) appended to 30903 and 99283 to represent the patient's nosebleed.

Payoff: The average national payout for 30901 is about $57 (1.1 transitioned facility relative value units [RVUs] multiplied by the 2011 Medicare conversion rate of 33.9764), while 30903 pays about $81 per encounter (1.54 RVUs multiplies by 33.9764).

So be on the lookout for any 30903 opportunities -- but be careful when choosing this CPT code.