Pediatric Coding Alert

Learn which modifiers to append and when to append them.

Children are widely known to resourcefully use their fingers to dislodge debris from their bodies, and their curiosity often leads them to insert other foreign objects that can cause bleeding. If a young patient presents to your pediatrician seeking nosebleed treatment, could you pick the right codes?

Compare your know-how with these three myths to see if your nosebleed, or epistaxis, treatment coding is up to snuff.

Myth 1: You Should Always Use 30901 or 30903 to Document Epistaxis Control

This is a myth because although pediatricians commonly see nosebleeds that originate toward the front of the nose, which you’d report with either 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) or 30903 (… complex (extensive cautery and/or packing) any method), CPT^® designates a separate code set for treating nosebleeds that occur in the back of the nose. This means there are two additional viable codes to consider: 30905 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial) and 30906 (… subsequent).

Select the right code based on bleeding location and patient status: Whenever the pediatrician determines anterior, or front-of-the-nose, epistaxis, you’ll select 30901 or 30903 for the treatment, depending on further details describing the limited or complex nature of the necessary cauterization or packing. That criteria does not apply to the posterior, or back-of-the-nose, epistaxis treatment codes, though. For posterior conditions, use 30905 to report the first time the provider controls a patient’s posterior bleeding. If bleeding reoccurs at that site, and the physician repeats posterior cautery or packing, submit 30906. If this occurs, keep in mind that there’s no guarantee that your insurer will pay for both cauterizations. Your 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’s 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) bundles 30901 and 30903 into 30905, you should submit only one same-side hemorrhage-control code for each encounter. So, if your provider performs anterior and posterior packing, report only 30905.

In addition, the NCCI bundles 30905 into 30906. Therefore, if a patient requires initial and subsequent posterior bleed control, you should only report 30906.

Myth 2: You Can’t Report Epistaxis Tx Without Cauterization or Packing

This is both true and false. You can’t report 30901, 30903, 30905, or 30906 without cauterization. However, that doesn’t mean you can’t report the encounter.

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

In this scenario, even though the provider packed the patient’s nostril, you won’t be able to use 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) because “there was no cautery performed or packing left in place to remain after the encounter,” per CPT^® Assistant (Volume 30, Number 7, 2020).

In situations such as this, where “simple procedures like ice and pressure succeed by themselves, an appropriate evaluation and management [E/M] service is appropriate,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant.” In this case, as your provider is treating a single, self-limited, or minor problem, and there is a low risk of morbidity from the treatment, that would be 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) for a patient established to your practice.

Remember: No matter which service code you report, you still need to show your payer that the service was medically necessary. In any of these cases, you’ll use R04.0 (Epistaxis).

Myth 3: You Can’t Report an 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 practitioner 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 explains they’ve had a lot of nasal congestion and sinus pressure in recent weeks. The physician sits back down and does a thorough history and evaluation of the condition. They discuss possible causes, environmental allergens, and the practitioner 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 could 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, which requires a medically appropriate history and/or examination and straightforward/low level of medical decision making …).

Remember: Even though the evaluation and the management is related to the same body system, the E/M in this scenario is significant and separate from the cauterization service. This means you’ll append 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) to the E/M code.

Modifier alert: Nosebleed treatment codes are unilateral. Codes 30901 and 30903 represent treatment on one nostril. If your physician performs nosebleed treatment on both nostrils, you should report 30901 or 30903 with modifier 50 (Bilateral procedure) attached. Alternatively, you can use modifier XS (Separate structure …) for Medicaid or payers that recognize Medicare guidelines, modifier 59 (Distinct procedural service), or the appropriate LT (Left side …) and RT (Right side …) modifiers (such as 30903-LT and 30901-RT)— again depending on payer preference — for separate-side bleed control.