ED Coding and Reimbursement Alert

Don't be surprised when patients with posterior bleeds present to the ED

When a patient reports to the ED for nosebleed treatment, odds are the physician will fix an anterior nosebleed. However, there is a chance that the physician will have to treat a posterior bleed, and you-ll code posterior bleeds differently than anterior ones.

The differences: While an anterior nosebleed is limited to the anterior portion of the nose, a posterior bleed is deeper in the nose and can be more difficult for the physician to control, says Elijah Berg, MD, FACEP, vice president of MRSI, an ED coding and billing company in Stoneham, Mass.

-A posterior bleed is often packed with an entirely different and more complicated type of device than an anterior bleed. While the physician stops most anterior bleeds with a nasal tampon or soft packing material, the physician will typically treat posterior bleeds with a dual-port nasal balloon,- he says.

Consider this example of a posterior nosebleed encounter, courtesy of Berg:

A patient with known coagulopathy from liver disease presents to the ED. He says that his nose has been bleeding for several hours and has not stopped, even though he applied pressure. The patient has had no other bleeding or bruising. The physician inspects the nasal mucosa and finds some minimal anterior bleeding and a large amount of blood coming from the posterior portionof the nasal vestibule.

The procedure note shows that the physician places a balloon and, despite inflating the anterior portion of the balloon, the hemorrhage continues. The physician then inflates the posterior portion of the balloon with control of bleeding. Labs are drawn, which confirm the patient's underlying coagulopathy. The physician also consults an ear, nose and throat doctor, and the patient is admitted to the hospital. 

On the claim, you should:

- report 30905 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial) for the posterior nosebleed treatment.

- report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the E/M service.

- append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99285 to show that the nosebleed treatment and E/M were separate services.

- report 784.7 (Epistaxis) and 286.7 (Acquired coagulation factor deficiency) with 30905 and 99285 to prove medical necessity for the encounter.

Prove Posterior Nosebleed With Thorough, Detailed Documentation

When reporting 30905, make sure you have airtight documentation proving a posterior bleed. -The physician should clearly indicate in the clinical note that it was a posterior bleed that was controlled in order for the 30905 code to be assigned by the coder,- Berg says.

Also, while it is possible for your ED physician to treat a posterior nosebleed, it is not a common ED code. When a patient has a posterior nosebleed fixed, it usually requires hospital admission, Berg says. You-re far more likely to encounter anterior nosebleeds in the ED.

(Note: For more information on coding anterior nosebleed treatments, see -Complex Anterior Nosebleeds Require Extensive Packing, Documentation- in this issue.)