Otolaryngology Coding Alert

Payoff: Difference in care could add hundreds to your bottom line.

A patient sees your ENT because of a persistent nosebleed, which your physician stops. Instead of automatically assigning 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) and moving to the next claim, stop to be sure you aren’t overcoding – or in some cases, undercoding – the encounter.

Minimal Treatment Means E/M Coding

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, says Todd Thomas, CPC, CCS-P, president of ERcoder, Inc., in Edmond, Ok.

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.

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.

More Extensive Stoppage Merits Procedure Codes

If your physician’s documentation indicates that the encounter involved more extensive stoppage techniques — such as using silver nitrate sticks or a small amount of cautery or packing — choose 30901 for the service. 

Tip: Your provider should include a procedure note, separate from the E/M documentation, if applicable, showing that the bleed was stopped with packing or cautery. Having this documentation helps justify the procedure code in addition to E/M. If the payer follows CCI (Correct Coding Initiative) rules (such as Medicare), remember that CCI 19.0 and 19.2 outlined new guidelines and bundling rules for reporting an E/M service with modifier 25 during the same encounter as a minor procedure. 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 received after colliding head-on with his son during horseplay. The patient says it has been bleeding steadily for about four hours and he rates the pain 7 on a scale of 10. 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
• 9213 for the established patient 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 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.
• 784.7 (Epistaxis) appended to 30901 and 99213 to represent the patient’s nosebleed.

Any physician treatment of an active nosebleed is likely going to support the assignment of a nosebleed treatment CPT^® code, according to Thomas.

Several factors can qualify the nosebleed care for 30901. You might be able to report 30901 if notes indicate that the ENT performed one of the following to treat a nosebleed:

• Chemical cautery with a silver nitrate stick;
• Brief electro-cautery; or
• Packed the nose with pledgets or a limited amount of gauze.

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, Thomas explains.

Rhinorocket Could Seriously Boost Bottom Lines

In extreme cases, your ENT 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 and taking blood thinners 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. The 25 modifier is supported because the complexities of the long term anticoagulants related to the nosebleed were managed via the E/M service. This should be made clear in the documentation.
• 784.7 and 401.9 (Essential hypertension, unspecified) appended to 30903 and 99213 to represent the patient’s nosebleed and related comorbidity. Link 784.7 and 401.9 to procedure code 30903, then list 784.7 linked to E/M code 99213. As a secondary diagnosis, you may also want to append a V code reflecting the patient’s use of blood thinners, such as V58.61 (Long-term [current] drug use; long-term [current] use of anticoagulants) or V58.63 (Long-term [current] drug use; long-term [current] use of antiplatelets/antithrombotics).

Payoff: The average national payout for 30901 is about $98 ($98.33 non-facility Medicare fee, based on the 2013 national average Medicare conversion rate of $34.023), while 30903 pays about $216 per encounter ($216.39 non-facility Medicare fee, based on the 2013 national average Medicare conversion rate of $34.023).