Otolaryngology Coding Alert

We’ll show you when to charge higher-valued nosebleed treatment and endoscopy.

Because CPT® contains five nasal hemorrhage-control codes, you may question when each description applies. But if you understand simple versus complex, initial versus subsequent, and when to code endoscopic hemorrhage control, you’ll get the right 30901-30906 or 31238 code.

Have you ever thought a nosebleed-control chart note sounds as if it warrants more than 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) or if you should use the same code for posterior bleed control?

You no longer have to wonder about the differences between the five epistaxis-control codes thanks to these tips:

1. File 30901-30903 for Frontal Bleeding

When your otolaryngologist uses cautery and/or packing to control anterior bleeding, you should report 30901 or 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).

Choose the appropriate code based on the hemorrhage-control amount and nosebleed severity. If the otolaryngologist applies cautery and/or packing to limited nasal frontal areas, submit 30901. For difficult-to-control hemorrhages or multiple bleed areas, assign 30903.

2. Assign 30905-30906 for Posterior Bleed Control

CPT® designates a separate code set for treating nosebleeds that occur in the back of the nose (30905, Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial; and 30906, … subsequent). Don’t apply the above limited/difficult criteria to these codes.

Better way: Select the right code based on the patient’s status. The first time an otolaryngologist controls a patient’s back-of-the-nose (nasopharynx) bleeding, report

30905. If bleeding reoccurs at that site and the otolaryngologist repeats posterior cautery and/or packing, submit 30906.

3. Code Epistaxis per Side and Visit

Because the Correct Coding Initiative (CCI) bundles 30901 and 30903 into 30905, you should submit only one same-side hemorrhage-control code for each encounter. So if your otolaryngologist performs anterior and posterior packing, report only 30905.

In addition, CCI bundles 30905 into 30906. Therefore, if a patient requires initial and subsequent posterior bleed control, you should report 30906.

Quick tip: Use modifier 50 (Bilateral procedure) for bilateral epistaxis control. Because 30901-30905 are unilateral codes, you should report cauterization per side.

For instance, a patient requires limited left and right anterior packing. Assign 30901-50 to indicate that the otolaryngologist packs each nasal passage. Alternatively, you should use modifier 59 (Distinct procedural service) for separate-side bleed control.

Suppose your otolaryngologist performs simple anterior cautery on a patient’s right nose and anterior complex packing on the left side. Submit the claim as 30903, 30901-59. Modifier 59 tells the insurer that the complex hemorrhage control occurred on a different side from the simple cautery. If the payer processes the modifiers for laterality properly, instead of modifier 59, you can use the appropriate LT and RT modifiers, for example 30903-LT and 30901-RT. But this option is only available with payers who do not bundle procedures when the separate sites are identified with body area modifiers as available in the CPT® Appendix A.

4. Reserve 31238 for Scope-Necessary Cautery

Now that you know the four main epistaxis-control codes’ requirements, you may wonder when to charge the endoscopy codes. What fulfills 31238’s requirements?

You should report 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage) when the otolaryngologist can’t stop the bleeding without the endoscope. But the otolaryngologist can’t simply use the scope as an aid to see the area. He must use the endoscope to control epistaxis.

You try: A patient presents with a bleeding nose. The otolaryngologist performs nasal endoscopy (31231) to locate the source of the bleeding. He then extensively cauterizes the patient’s nasal anterior.

In this case, submit only the surgery code (30903).

Do not code 31231 along with 30903 because the diagnostic nasal endoscopy code (31231) is bundled with all of the above control of nasal epistaxis codes 30901-30906. When the physician is performing the nasal endoscope only for visualization, you should not use 31238. In the above description, the otolaryngologist did not place the electrocautery tool parallel to the endoscope to burn the nasal tissues; he is using the endoscope as a tool to control the epistaxis. If, however, the otolaryngologist uses the scope to control the bleeding and the documentation shows that the endoscope was not just used to locate the site of the bleed, you should submit 31238.

You shouldn’t separately report the cautery. Code 30903 is incidental to 31238.

5. Apply Endoscopy Edit to 30901-30906

In the above cautery example, don’t be tempted to bill both the surgery and the diagnostic procedure. CCI bundles 30901-30906 into 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]).

Pay attention: This is a backward edit. CCI usually bundles the diagnostic procedure (31231) into the surgery (30901-30906), not the other way around. Thus, when your otolaryngologist performs a diagnostic endoscopy prior to cautery and/or packing, you should report the higher-valued code.

Careful: All hemorrhage control codes except 30901 pay more than endoscopy (31231). So when your otolaryngologist performs endoscopy prior to epistaxis control (codes 30903-30906), you should submit the surgical procedure. But when he uses endoscopy prior to simple cautery, report the diagnostic procedure because it pays more.

Bottom line: With all epistaxis-control codes except 30901 (the lowest-valued procedure), you should submit the surgery code instead of 31231. Here’s how to apply this rule:

Suppose a patient comes in to the office complaining of headaches, nasal obstruction, and post nasal drip. As part of this office visit, the physician performs a diagnostic nasal endoscopy (31231).

Then early that evening, the patient arrived in the emergency room with a nasal hemorrhage because his nose is so dry, and the ER doctor cannot control the epistaxis. The ER doctor calls your physician in to assist with this patient. Your doctor goes to the ER and performs a complex anterior control of epistaxis via packing (30903).

How would this be coded and billed since these two codes are considered bundled and they were performed on the same day?

Since they were performed at different encounters and in different places of service (office and then in the ER), both codes are billable. In this case, they would be billed 31231 with the diagnoses from the office visit with a place of service office (11) and then on another claim (you need to separate claims when the POS changes) bill 30903-59 with ICD-9 784.7 for epistaxis and the POS of ER (23). Note: In ICD-10, 784.7 will become R04.0 (Epistaxis).