Otolaryngology Coding Alert

Question: The provider’s notes read that the patient had a large blood clot with oozing in the right nasal cavity. The provider sprayed the nasal cavities bilaterally with Afrin and suctioned the clot clear bilaterally. After applying more Afrin topically, the provider noted that no further significant bleeding on the right or left.

The provider submitted 30901 to document this, but I don’t think that it is the appropriate code as he’s not controlling bleeding. Is he correct?

AAPC Forum Participant

Answer: Yes, your provider would be correct in coding this procedure as 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method). That’s because the procedures they describe in their notes — suction and the application of nasal spray — more closely fit the “simple” part of the descriptor. The note does not describe any of the procedures (cautery or packing, for example) that would be typical for a more complex service, which you would code to 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method).

Choosing 30901would still be appropriate regardless of whether the provider had completely stopped the patient’s bleeding, as the descriptor only indicates that the hemorrhage is under control.

Remember to follow the CPT^® instructional note that accompanies the code, which tells you to use modifier 50 (Bilateral procedure) if the provider has performed the procedure bilaterally. In this particular case, as the provider sprayed and suctioned the patient’s nasal cavity bilaterally, you should append modifier 50 to the 30901.