Otolaryngology Coding Alert

Otolaryngologists often use a scope when controlling epistaxis (nosebleeds). And CPT provides a specific code (31238, nasal/sinus endoscopy, surgical; with control of epistaxis) for when endoscopies are used to control epistaxis. But billing this code is not always so straightforward.

Code 31238 is a surgical endoscopy code and is not appropriately billed if the same service could be performed without the scope, says Randa Blackwell, a coding specialist with the department of otolaryngology at the University of Maryland in Baltimore. The old coding guideline applies here, says Blackwell. If instrumentation is used in a procedure because it is needed, you can bill for it. But if it is used primarily to assist the physician, then it shouldnt be billed.

In the case of epistaxis control using the endoscope, this guideline has been turned on its head by Medicares national Correct Coding Initiative, which bundles epistaxis control procedure codes into diagnostic endoscopy, instead of the other way around. But the principle still holds: If the scope is being used to make it easier for the otolaryngologist to control the bleeding, only the endoscopy may be billed.

Coding Epistaxis With Diagnostic Endoscopy

In fact, there are several distinct scenarios involving epistaxis, and each is coded differently.

CPT 2000 lists four codes that should be used when the otolaryngologist controls bleeding in the nose. The first two, 30901 (control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) and 30903 (complex [extensive cautery and/or packing] any method) are used for nosebleeds in the front of the nose.

In both cases, the bleeding areas are seen easily.
Codes 30905 (control nasal hemorrhage, posterior, with posterior nasal packs and/or cauterization, any method; initial) and 30906 (subsequent) are used to stop bleeds at the back of the nose. The otolaryngologist packs the nose anteriorly and posteriorly and occasionally performs electrical coagulation.

The otolaryngologist may use an endoscope to examine the nasal passages to determine the location and severity of the bleeding. If he treats the epistaxis by packing the anterior section of the nose as a result of this examination, only 31231 (nasal/sinus endoscopy) should be billed because 30901 is bundled with 31231, according to Medicares national Correct Coding Initiative, says Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C.

Callaway-Stradley notes that 30903, 30905 and 30906 also are bundled into 31231. But because these are more complex procedures and consequently have been assigned a larger number of relative value units (RVU), even if the otolaryngologist uses the scope while performing any of these procedures, only the appropriate epistaxis code should be billed because it reimburses at a (slightly) higher rate than the endoscopy. When the procedure performed is described accurately by one of these four epistaxis codes, she says, the endoscope serves as an aid to visualize the area, but other methods are used to control the bleeding.

Note: According to the 1999 National Physician Fee Schedule Relative Value Guide, the RVUs for these procedures is as follows: 30901, 1.87; 30903, 2.52; 30905, 4.04; 30906, 3.71; 31231, 2.71; 31238, 7.51.

When Is It OK to Bill 31238?

Occasionally nasal bleeding does not respond to the more conservative methods outlined above or is so severe that the patient requires rapid control to avoid nasal packing for patient comfort. In those instances, the otolaryngologist uses the endoscope both to locate the bleed and places electrocautery, laser instruments and/or chemical cautery parallel to the scope to stop the bleeding.

Otolaryngologists should note that in these cases, the bleeding could not have been stopped or visualized without the use of the endoscope, and this should be the determining factor when deciding to bill with 31238.

Similarly, if the otolaryngologist uses the scope to assist in controlling the bleeding by more traditional means and determines the patient has a sinus problem, billing with 31238 is inappropriate, Blackwell says. She notes that in that situation, with two separate diagnoses and separate instrumentation, the two procedures (31231 and 3090x) arent related. If cautery then is performed using the scope, however, 31238 should be billed.