Internal Medicine Coding Alert

Warning: Reporting 30901 for ice stoppage might not be proper. A patient comes to your office with a nosebleed, and your internist stops it. Before you code with 30901 and move on to the next chart, consider this point: Submitting 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) could be overcoding in some situations --" or undercoding (thus losing big bucks per encounter) in others. Stop unintentionally bleeding your bottom line with advice from the experts on how to handle patients with nasal hemorrhages. Minimal Stoppage Is E/M Territory Always check how involved repair was before choosing a nosebleed repair code. Here's why: Some nosebleed fixes are actually E/M services, says Kathy Plato, CPC, director of coding education and 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, you should choose an E/M code, Plato says. Select from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), depending on the patient's status and how much face-to-face time your physician spends. When the physician uses minimal stoppage methods, "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 E/M level. Example: An established patient reports to your office 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 stops, and the physician discharges the patient. You would report 99213 for the entire encounter. Nitrate Sticks, Cautery Mark CPT-Level Fixes If your physician's documentation indicates that the encounter involved more extensive stoppage techniques -- such as using silver nitrate sticks or a small amount of cautery or packing -- choose 30901 for the service, along with any E/M service that the physician might provide, says Plato. "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. Example: An established patient presents 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'll report: 30901 for the repair 99213 for the established patient 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 99213 to show the nosebleed repair and E/M were separate services 784.7 (Symptoms involving head and neck; epistaxis) appended to 30901 and 99213 to represent the patient's nosebleed. Rhinorocket Could Seriously Boost Bottom Lines In extreme cases, your internist might also perform a complex anterior nosebleed repair. You would code the procedure 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 explains. Example: A 54-year-old established patient with a history of essential hypertension and taking blood thinners presents with a gushing nose bleed following a prolonged sneezing fit. The 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. Your claim should include: 30903 for the repair 99214 for the E/M Modifier 25 appended to 99214 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 99213 to represent the patient's nosebleed. Payoff: The average national payout for 30901 is about $95 ($95.81 non-facility Medicare fee, based on the 2011 national average Medicare conversion rate of 33.9764), while 30903 pays about $196 per encounter (non-facility fee, based on the conversion rate of 33.9764). So be on the lookout for any 30903 opportunities -- but be careful when choosing this CPT code.