Otolaryngology Coding Alert

Plus: Don’t forget you have different codes for posterior bleeds.

A patient comes to your office complaining of a persistent nosebleed. Your physician stops the bleed, but that doesn’t mean you stop looking at code choices once you reach 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method). Why? Because you might be either overcoding or undercoding, depending on the situation.

Look to E/M Codes for Minimal Stoppage Techniques

Treating the patient for epistaxis (nosebleed) because of minor active bleeding might not support reporting a procedure code when the physician instructs the patient in self-administration home remedies such as applying ice or direct pressure. You also won’t report a procedure code if the ENT stops the bleeding with standard, minimal methods. Instead, choose the appropriate E/M code and report the service as an office visit.

Options: 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.

Example: An established patient reports to your office with a nosebleed. She says the bleeding has been “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.

Key point: When your physician uses minimal methods to stop the bleeding, he or she has not performed a separately billable service. An E/M code will suffice.

Choose a Procedure Code for More Involved Care

If the notes indicate that the encounter involved more extensive stoppage techniques — such as using silver nitrate sticks or a small amount of cautery or packing — report 30901 for the service, along with the code for any E/M service that the physician also might provide.

Tip: Your provider should include a procedure note, separate from the E/M documentation, if applicable, showing that she stopped the bleed with packing or cautery. Having this documentation helps justify the procedure code in addition to E/M. Be sure you can support that a significant, separately identifiable E/M service was performed before submitting it with the minor procedure. Even if the payer in question doesn’t follow CCI bundling rules, CPT^® also has guidelines for correctly reporting these encounters.

Example: An established patient presents with a nosebleed he says has been bleeding steadily for about four hours; he rates the pain as 7 on a 10-point scale. 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 or other qualified health care professional on the same day of the procedure or other service) appended to 99213 to show that the control of the nosebleed and E/M were separate services. The 25 modifier is supported because the otolaryngologist was ruling out a fractured nose, which is “unrelated” to the epistaxis.

• R04.0 (Epistaxis) appended to 30901 and 99213 to represent the patient’s nosebleed.

Key terms: When deciding on a nosebleed treatment code, look for phrases such as “hemostasis” (control of bleeding), “bovie,” “silver nitrate,” “electrocautery,” or “chemical cauterization.” These terms would indicate a procedure.

Check for Complex Repair to Recoup Even More

In extreme cases, your otolaryngologist might also perform a complex anterior nosebleed repair. If so, you should code the procedure with 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).

Distinction: A complex nosebleed repair would be more aggressive, such as difficulty stopping the bleed, nasal packing, maybe a rhinorocket or an epistaxis balloon.

Example: A 54-year-old established patient with a history of essential hypertension 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. He then provides topical anesthesia and places a rhinorocket to control the bleeding. Your claim should include:

• 30903 for the repair
• 99213 for the E/M
• Modifier 25 appended to 99213 to show the nosebleed repair and E/M were separate services.
• R04.0 and I10 (Essential [primary] hypertension) appended to 30903 and 99213 to represent the patient’s nosebleed and related comorbidity. Link both diagnoses to procedure code 30903, then list R04.0 linked to E/M code 99213.

Payoff: The average national payout for 30901 in an office setting is about $98 ($97.39 non-facility Medicare fee, based on the 2016 national average Medicare conversion rate of $35.804). By contrast, code 30903 for rhinorocket placement pays about $226 per encounter ($225.93 non-facility Medicare fee, based on the 2016 national average Medicare conversion rate of $35.804).

Shift Codes for Posterior Bleeds

 If your physician treats a posterior nose bleed, you’ll turn to a different set of CPT^® codes for reporting the service:

• 31238 — Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage
• 30905 — Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
• 30906 — … subsequent.

Special notes: “Remember that if a diagnostic endoscopy is performed to locate the source of the bleed, 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) is bundled and not billable,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. “Performing a diagnostic endoscopy and then packing the nose is not the same as an endoscopic control of a nasal hemorrhage, which is represented by 31238. That’s why you cannot combine both services into 31238.”