Internal Medicine Coding Alert

Question: An established 60-year-old established patient reports to the internist with a bleeding left nostril. She tells the internist that it started about three hours ago, and she could not stop it on her own. After a level-two E/M, the internist cauterizes the nostril with a silver nitrate stick and then packs the nostril extensively to soak up the blood. Should I code this as a simple or complex procedure?

Missouri Subscriber

Answer: Since the internist needed to use cautery and extensive nasal packing, you'll be able to report the service with 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method). So on the claim, report the following:

• 30903 for the nosebleed treatment

• 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; straightforward medical decision-making) for the E/M

• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to 99212 to show that the E/M was separate from the nosebleed treatment

• 784.7 (Epistaxis) attached to 30903 and 99212 to prove medical necessity for both services.

Be sure to include a description of the cautery and packing in the documentation. This will alert the payer that you took the extra steps to justify reporting 30903.

On a 30903 claim, a payer is likely to want to see:
• indications for the procedure
• techniques used to stop bleeding
• patient response to bleeding prevention techniques
• name of the medical professional who performed the treatment.