Internal Medicine Coding Alert

Multiple attempts, certain methods mark CPT-approved treatments

When your internist treats a patient's nosebleed, the condition's severity will likely affect your code choice for the encounter.

Why? For less serious nosebleeds, your physician's actions won't meet CPT's definition for nosebleed treatment. In these situations, you'll have to turn away from CPT's nasal hemorrhage treatment section and choose another code for the encounter.

The key: Before choosing a nosebleed treatment code, check the internist's documentation to see if the encounter meets CPT parameters for nasal hemorrhage treatment.

Nosebleed Treatment Could Be an E/M Service

You'll end up coding a portion of your nosebleed presentations with an appropriate E/M code, confirms Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC in Deer Park, Ill. When the internist stops the bleeding with standard methods, such as ice or pressure, then you should report the service with an E/M code.

Example: An established patient presents with mild left nasal bleeding. The physician performs a problem-focused history and exam, and applies 10 minutes of direct pressure to the left nostril. After the pressure, a repeat assessment of the nostril shows the bleeding has stopped.
 
In this instance, report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making). Also, attach ICD-9 784.7 (Epistaxis) to 99212 to represent the nosebleed.

Limited Packing Likely Means Simple Treatment

When the nosebleed takes more involved methods to stop, such as cautery or nasal packing, you'll be able to report the service with 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method).

Report this code for nosebleed treatments that involve one attempt at cautery or packing placement in the nostril's anterior part that controls the bleeding on the initial attempt.

You'd code 30901 "if the physician took a silver nitrate stick to stop an anterior nose bleed or packed the nose with a cotton pledget," explains Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.

Consider this example: A 45-year-old male established patient reports that his right nostril started bleeding two hours ago and trying to put pressure against the nostril failed to stop it.

During the course of a level three E/M service, the physician finds the patient is otherwise healthy and has no other bleeding. The internist examines the patient and discovers persistent ooze from the septum during a check of the right naris.

The physician places cotton strips soaked in Pontocaine and Epinephrine in the patient's right naris for 15 minutes. There is an obvious bleeding site after the physician removes the strips, which he cauterizes with a silver nitrate stick.

This is an example of a simple anterior treatment. On the claim, report the following:

• 30901 for the nosebleed treatment
• 99213 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of low 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) attached to 99213 to show that the E/M was separate from the nosebleed treatment
• 784.7 attached to 30901 and 99213 to prove medical necessity for both services.

Documentation alert: On your 30901 claims, the procedure note should reflect the type of treatment provided, such as cautery or packing. Gilhooly recommends that coders discourage their internists from just writing "controlled nosebleed" in the medical record.

"You need to have a separate procedure note because there are many things that could cause the nosebleed," Gilhooly explains.

Coders that want their internists to be more accurate on their nosebleed treatment documentation could ask them to include the following in the claims:

• indications for the procedure
• techniques used to stop bleeding
• patient response to bleeding prevention techniques
• name of professional who performed the treatment.

Multiple Attempts? Look to 30903

When your internist treats a patient with a more serious nosebleed, he may need to try several different methods, or the same method several times, to stop the bleeding. In these cases, you might be able to report 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method) for the nosebleed treatment.

Techniques employed: "When your physician performs an extensive treatment, the technique should involve bleeding that needs more then spot cautery or use of simple packing," according to Linzer. The internist may use nasal packing with Vaseline, gauze or nasal tampons during a complex treatment.

Example: An established patient reports to the internist after being hit in the nose and has significant bleeding from the right nostril. During exam, the internist notes significant bleeding from the middle and inferior turbinates and the nostril floor. The internist places an expandable cellulose nasal pledget that has been soaked in antibiotic ointment and oxymetazoline into the anterior of the patient's nose.

In this instance, the physician performed a complex treatment. On the claim, report 30903 for the treatment with 784.7 attached to represent the nosebleed.

Documenting for this claim should include proof that the treatment was for more then just a simple bleed, says Linzer. Gilhooly agrees, saying, "I expect to see the physician be very descriptive on 30903 claims."