Otolaryngology Coding Alert

Don't let the extra $100 go by because of wrong judgement.

When you're faced with an active nosebleed control coding situation and you don't know what to do, you might be missing out as much as $196 in reimbursement. Being able to discern a reportable nosebleed control encounter from an E/M is a good first step to coding success, but you have other factors to consider.

The following myths could clarify some of your concerns, based on this scenario:

An established patient reports to the office after sustaining injuries during a soccer game. A ball hits her in the face, which makes her nose bleed and gives her a black eye on the right side. The physician documents a detailed history, performs a detailed exam and medical decision making is of moderate complexity. The patient also complains of a headache and facial pain in addition to the nose bleed. The otolaryngologist cannot stop the bleeding with ice or pressure, so she performs repeated and extensive cautery using a silver nitrate stick on both nostrils. The bleeding finally stops, and the physician orders an x-ray to ensure that the patient's nose is not broken. Results came back negative from the x-ray. How should you report it?

Myth #1: All Nosebleeds Are The Same

You should be on the lookout for the type of nosebleed control your physician performs. In the above example, you should report the given scenario with:

• 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] and method) for the complex repair
• modifier 50 (Bilateral procedure) appended to 30903 to show that the physician treated both nostrils
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) for the 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 99214 to show that the E/M and repair were separate services
• 784.0 (Headache and facial pain) appended only to the E/M service, 99214-25
• 784.7 (Epistaxis) appended to 30903 and 99214-25 to represent the patient's nosebleed
• E917.0 (Striking against or struck accidentally by objects or persons; in sports without subsequent fall) appended to 30903 and 99214-25 to represent the cause of the patient's nosebleed
• E007.5 (Activities involving other sports and athletics played as a team or group; soccer) appended to 30903 and 99214-25 to represent the circumstances surrounding the patient's nosebleed.

Revenue Opportunity: The calculated Medicare revenue based on RVUs for 30903 is about $196.04 per claim (5.77 RVUs multiplied by 2011 conversion factor of 33.9764). CPT 30903's counterpart is 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), which describes simple nosebleed repair. For your 30901 claim, you can get about $95.81 per claim from Medicare without any geographical adjustment (2.82 RVUs multiplied by 2011 conversion factor of 33.9764). That's an extra $100 difference between the two codes, so make sure you're coding accurately based on the documentation and what was performed.

Myth #2: Physician's Notes Tell You Nothing

On the contrary, your physician's notes should be telling when you're choosing between 30901 and 30903. For 30901, the notes should indicate the following:

• applied continuous pressure
• inserted pledgets soaked with an anesthetic-vasoconstrictor solution into the nasal cavity
• administered nasal spray to anesthetize/shrink nasal mucosa
• performed chemical cautery with a silver nitrate stick.

Meanwhile, you should consider 30903 when the physician makes several attempts to stop the bleeding, either via the same method or different methods. Additionally, the physician might use "more aggressive treatment" on complex nosebleed repairs, says Todd Thomas, CPC, CCS-P, president of ERcoder Inc. in Edmond, Ok. These methods include traditional nasal packing (gauze), a prefabricated nasal sponge, or an epistaxis balloon.

Myth #3: Nosebleed Repair Coding Ends With 30901, 30903

Sometimes, the physician would be able to stop the bleeding using basic methods. In this case, an E/M code would be appropriate. "Basic methods" can include ice or brief direct pressure.

In the same manner, when patients present to the office complaining of nosebleed, but the physician sees no active bleeding, you should use an E/M code.

Example: Say the physician from the given scenario stops the bleeding with ice, you should report only one CPT code: 99214 for the E/M. Then, you should link 784.7 to 99214 to describe the nosebleed.