Otolaryngology Coding Alert

Question: A new patient presents complaining of chronic nosebleeds. During the exam, her nose begins to bleed and the otolaryngologist packs the nose. Should I report 99201-99205 in addition to 30901?

Colorado Subscriber

Answer: In this case, the otolaryngologist performs a significant, separately identifiable service in addition to the hemorrhage control. Therefore, you should report the procedure (30901*, Control nasal hemorrhage, anterior, simple [limited cautery and/or packing], any method) and 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 the appropriate E/M service level (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient).

Using different diagnoses, if appropriate, such as 456.8 (Varices of other sites; varicose veins of nasal septum [with ulcer]) for 9920x and 784.7 (Epistaxis; hemorrhage from nose, nosebleed) for 30901, will bolster your case that the office visit is a significant, separately identifiable service from the epistaxis control.