Otolaryngology Coding Alert

Here’s your guide to reporting E/M codes or 30901.

A patient comes to your office with a nosebleed, and your otolaryngologist stops it. Your automatic thought might be to report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), but don’t move too fast. Submitting 30901 could be overcoding in some situations – or undercoding in others. Read on for what you need to know about correctly reporting the situation. 

Stick With E/M for Minimal Treatment Methods

Your first step should be to check how involved the repair was before choosing a nosebleed code. That’s because some nosebleed fixes actually should be reported as E/M services.

If a patient reports to the physician with a nosebleed, and the physician stops the bleeding with standard, minimal methods such as ice or pressure, you should choose an E/M code. 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 the specifics of the encounter. 

When the physician uses minimal stoppage methods, “no separate billable procedure was performed,” says Jeffrey Linzer Sr., MD, FAAP, FACEP, associate professor at Emory University School of Medicine in Atlanta. Instead, you roll the work into the overall E/M level of service. 

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.

Nitrate Sticks or Cautery Point to Multiple 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 for an anterior bleed-- choose 30901 for the service, along with any E/M service that the physician might provide.

“There would need to be a procedure note, separate from the E/M documentation, if applicable, showing that the bleed was stopped with packing or cautery,” Linzer says.

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 (784.7). The physician makes a few swabs with silver nitrate sticks to stop 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 the nosebleed repair and E/M were separate services because the physician needed to rule out a fractured nose. Code 99213 is considered a Column 2 code of 30901, based on the CCI (Correct Coding Initiative) update of July 2013. This means that it is very important for the otolaryngologist to document any details supporting why the two codes are both payable via the 25 modifier. In this case, ruling out a fractured nose separated the services and justified reporting both codes.
• Diagnosis 784.7 appended to 30901 and 99213 to represent the patient's nosebleed. 

Complex Repair Might Mean Higher-Level Codes 

In extreme cases, your physician might also perform a complex anterior nosebleed repair. These encounters involve more complicated methods to treat, such as nasal packing and possibly a rhinorocket or epistaxis balloon. If so, you would code the procedure with 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).

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. The physician 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
• Diagnoses 784.7 and 401.9 (Essential hypertension, unspecified) appended to 30903 and 99213 to represent the patient’s nosebleed and related comorbidity. You might also want to append a V code reflecting the patient’s use of blood thinners, such as V58.61 (Long-term [current] use of anticoagulants) or V58.63 (Long-term [current] use of antiplatelets/antithrombotics). 

Payoff: The average national payout for 30901 is $97.44 for a non-facility service (based on the 2014 national average Medicare conversion rate of $35.8228). Code 30903 pays $210.64 for non-facility service, based on the same Medicare conversion rate.

Bottom line: Being able to report 30903 can boost your reimbursement, but be careful when reporting this CPT® code. Always ensure that your physician’s documentation supports whatever code you submit, especially when you’re unbundling the E/M code and the minor procedure in order to report both services.