Otolaryngology Coding Alert

Procedure Focus:

Get Your Epistaxis Coding Under Control Using These 4 Q&As;

Published on Thu Aug 10, 2023

Remember: An E/M encounter may be all you need to report nosebleed treatment.

When you face a chart for the treatment of a nosebleed, there are certain details you need to pay attention to in order to select the procedure code that accurately represents the service. You must also consider whether a hemostasis code is even the right way to go about reporting your provider’s management of the patient’s condition.

Ask these four questions to narrow your options and ensure proper code assignment.

Question 1: Is It an Anterior or Posterior Nosebleed?

A nosebleed, also called epistaxis, is represented by several codes, and knowing which to choose and in which circumstance is crucial to coding the encounter. When your otolaryngologist treats an anterior nosebleed, one that originates toward the front of the nose, you should report either 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) or 30903 (… complex (extensive cautery and/or packing) any method).

Tip: Simple procedures may include ice and pressure. “Complex is intended to mean deeper into the canal … or multiple applications of the coagulation method. It could also include additional layers of packing,” explains Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting.

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).

Base code selection on bleeding location and patient status: Whenever the otolaryngologist treats an anterior nosebleed, you’ll use 30901 or 30903 for the hemostasis, depending on further details describing the limited or complex nature of the necessary cauterization or packing. That criterion does not apply to the posterior, or back-of-the-nose, epistaxis treatment codes, though. For posterior bleeds, use 30905 to report the first time the provider controls a patient’s posterior epistaxis. If bleeding reoccurs at that site, and the physician repeats measures such as posterior cautery or packing, submit 30906. Your otolaryngologist’s chart notes should clearly describe the circumstances and emphasize that the patient’s condition was not resolved, and a second treatment was, therefore, medically necessary.

Remember: Whether the cauterization procedure is simple or complex is up to the provider’s judgment. “CPT^®does not define ‘simple’ or ‘complex’ in this context. Instead, code choice is at the discretion of the physician and is based on the level of difficulty involved in the procedure,” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Coding alert: Because the National Correct Coding Initiative (NCCI) edits bundle 30901 and 30903 into 30905, you should submit only one same-side hemorrhage-control code for each encounter. So, if your provider treats both anterior and posterior bleeds, report only 30905.

Question 2: Did Epistaxis Control Include Cauterization or Packing?

This detail is key, as you can’t report 30901-30906 without the use of packing or nasal cautery to achieve hemostasis. However, that doesn’t mean you can’t report the encounter.

Example: An established patient presents with mild bleeding in the left nostril. The physician performs a history and exam, determines it’s an anterior bleed, then applies direct pressure to the affected nostril before applying a cotton swab into the nostril. After a few minutes, the provider removes the swab, examines the patient’s left nostril a second time, and notes the bleeding has stopped.

In this scenario, even though the ENT packed the patient’s nostril, you won’t be able to use 30901 because “there was no cautery performed or packing left in place to remain after the encounter,” per CPT^®Assistant (Volume 30, Number 7, 2020).

Instead, “If simple procedures like ice and pressure succeed by themselves, an appropriate evaluation and management [E/M] service is appropriate,” says Chip Hart, director of Pediatric Solutions at Physician’s Computer Company in Winooski, Vermont. In this case, as the provider is treating a single, self-limited, or minor problem, and there is a low risk of morbidity from the treatment, that would probably be 99212 (Office or other outpatient visit for the evaluation and management of an established patient … straightforward medical decision making …) for a patient established to the practice.

Don’t forget the diagnosis: No matter which service code you report, you still need to show your payer that the service was medically necessary. The most common presentation for nosebleed control is R04.0 (Epistaxis) — but there are other ICD-10-CM codes that may fit the bill.

Question 3: Does ENT Work Justify Reporting E/M With Cauterization?

Cauterization is usually straightforward and doesn’t require an extensive E/M service. However, that doesn’t mean you will never report an E/M service alongside the procedure.

Let’s say an established patient reports that their right nostril started bleeding two hours ago and they were unable to stop it with pressure alone. The otolaryngologist places cotton strips soaked in Pontocaine and epinephrine in the patient’s right nostril for 15 minutes. After the physician removes the strips, bleeding still occurs from the same nostril, which the physician cauterizes with a silver nitrate stick. As the physician is cleaning up, the patient reports they’ve had a lot of nasal congestion and headaches from sinus pressure in recent weeks. The physician sits back down and does a thorough history and evaluation of the condition. They discuss possible causes, and the ENT makes several over-the-counter medication suggestions, as well as a request for a two-week follow-up.

The nosebleed management is an example of a simple anterior treatment for which you’d report 30901 in addition to the E/M, probably either 99212 or 99213 (Office or other outpatient visit for the evaluation and management of an established patient … low level of medical decision making …).

And remember: Since the E/M is significant and separate from the cauterization service, you’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) to 99213.

Note, the diagnosis linked to the 99213-25 would not be epistaxis. Instead, you should use diagnoses such as R09.81 (Nasal congestion) and/or R51.9 (Headache, unspecified) for the presenting symptoms, as these are the basis for the additional workup. Linking the appropriate ICD-10-CM codes to the E/M will help support the “significant and separately identifiable” nature of the E/M service.

Question 4: Do I Need a Laterality Modifier for Complete Coding?

Anterior nosebleed hemostasis codes are unilateral. In other words, 30901 and 30903 represent the treatment of one nostril.

So if the otolaryngologist controls anterior epistaxis in both nostrils, you’ll need to report the code once with modifier 50 (Bilateral procedure), twice with modifier 50 appended to the second code, or with modifiers RT (Right side) and LT (Left side), depending on payer preference. Conversely, posterior epistaxis control codes represent a bilateral service, which means it’s not appropriate to code 30905 or 30906 with modifier 50 appended.