EM Coding Alert

Sometimes, an E/M encounter may incorporate a repair.

Coders need to know how to choose the right code when reporting a doctor’s repair of a nosebleed in an emergency department (ED) encounter.

A nosebleed, also called epistaxis, is represented by several codes, and knowing which to choose and in which circumstance is crucial to coding the encounter. Find out how to correctly code your provider’s nosebleed repair encounters.

Know ED-Specific Codes

In the ED setting, your nosebleed repairs will be reported with these codes:

An ED evaluation and management (E/M) service from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set

• 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method)
• 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method)

How you employ these codes, and which ones you use, will depend on the specifics of the encounter. Here’s a look at the common nosebleed presentations for each type of code:

ED E/M: You’ll report an ED E/M when the nosebleed repair does not reach the level of 30901.

“A coder can separate 30901 from an E/M service by the approach of the procedure. If a patient goes to the emergency department with a nosebleed and the physician controls the bleeding by applying external pressure, and also uses a cotton swab with phenylephrine and removed right after, then this would be included in the E/M service,” explains Marco Unzueta, BSHIM, CPC, CCS, CIC, CDEO, CDEI, AAPC Approved Instructor, medical coding supervisor at El Paso Children’s Hospital in El Paso, Texas.

30901: Citing Coder’s Desk Reference, Unzueta says you’ll report 30901 when the physician applies electrical or chemical coagulation or packing materials to the anterior (front) section of the nose. Only limited electrical or chemical coagulation is used during 30901 procedures, he says.

30903: Again, citing Coder’s Desk Reference, 30903, the physician uses extensive electrical coagulation or extensive packing in the anterior (front) section of the nose.

“Complex is intended to mean deeper into the canal … or multiple applications of the coagulation method. It could also include additional layers of packing,” explains Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting.

Important: If the nosebleed requires extensive packing or cauterization in both nostrils, you should append modifier 50 (Bilateral procedure) to the repair code to indicate that it was a bilateral procedure.

Figure Out When to Use ED E/M-25

There are also a couple of other services you could potentially code for during a nosebleed repair encounter. If the provider performs a significant, separately identifiable ED E/M before the nosebleed repair, then you can report it using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). You’ll need to have proof in the record that the provider performed a significant, separately identifiable E/M before the repair, complete with separate medical decision making (MDM) and history and exam (as appropriate).

Exception: If you’re coding the nosebleed repair itself with an ED E/M, you cannot report another ED E/M for the work the provider does before the repair. In these cases, you’d roll all the work of the encounter — E/M before the repair and the repair itself — together and choose an ED E/M based on that level of MDM.

For example, if the ED provider performs nosebleed repair with external pressure and cotton swabs that involves low-level MDM, but the pre-repair E/M services bump the MDM up to moderate, you’re allowed to report 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) instead of 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making).

Choose From These Dx Codes

The most common presentation for nosebleed repair will be R04.0 (Epistaxis) — but it’s not the only ICD-10-CM code that could prove medical necessity for 30901/30903. Your nosebleed repair patient might also present one of these diagnoses:

• I78.8 (Other diseases of capillaries)
• I78.9 (Disease of capillaries, unspecified)
• J95.61 (Intraoperative hemorrhage and hematoma of a respiratory system organ or structure complicating a respiratory system procedure)

• J95.62 (Intraoperative hemorrhage and hematoma of a respiratory system organ or structure complicating other procedure)
• J95.71 (Accidental puncture and laceration of a respiratory system organ or structure during a respiratory system procedure)
• J95.72 (Accidental puncture and laceration of a respiratory system organ or structure during other procedure)
• J95.830 (Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure)
• J95.831 (Postprocedural hemorrhage of a respiratory system organ or structure following other procedure)
• P54.8 (Other specified neonatal hemorrhages)

Note: This is not a definitive list of acceptable ICD-10-CM codes for 30901/30903. Always code to the notes, and check your payer contracts to see if they have any diagnoses listed for 30901/30903.

Consider These Examples

To illustrate the 30901 and 30903 concepts, here are a pair of examples from Martien:

Example 1: A patient presents to the ED with a complaint of a spontaneous nosebleed after sneezing repeatedly. The provider takes an appropriate history and examines the patient’s nose and throat. The provider can see the source of the bleeding, a small vessel in the major alar cartilage. Using silver nitrate, the provider treats the small bleeding vessel. Once coagulation is achieved, a small amount of packing of iodoform gauze is placed in the anterior nares over the vessel treated.

On the claim, you’d report 30901.

Example 2:

A patient presents to the ED with a complaint of a spontaneous nosebleed after being struck in the face by a baseball. Attempts to stop the bleeding with compresses, ice, holding the nose, and tipping the head back have not been helpful. The provider takes a history and examines the patient. The nose appears to be broken so a complete nasal X-ray is taken, which shows a nasal fracture of the septum at the bridge of the nose. After evacuating a few clots, the sites of bleeding are identified. There are two major sites of bleeding due to the trauma. As the nasal anatomy is not displaced only the nosebleeds require treatment. Both sites of bleeding are in the middle turbinates of the nose. Silver nitrate is held against the vessels to stop the bleeding. Once coagulation is achieved, packing is placed tightly against the vessels to maintain the coagulation. The patient is discharged with directions for care and instructions to see their PCP or return to the ED if the nosebleed persists.

On this claim, you’d report 30903 for the repair. Also, report 70160 (Radiologic examination, nasal bones, complete, minimum of 3 views) for the X-ray with modifier 26 (Professional component) appended to show that you are only coding for your provider’s interpretation of the X-ray.